Four years ago, Atrium Health in Charlotte, North Carolina, began a dramatic change in how it cares for newborns exposed to opioids in the womb.
Until then, most of the approximately 700 babies who suffered opioid withdrawal each year in the hospital system spent their first weeks in a neonatal intensive care unit (NICU), isolated from their parents and treated with regular doses of morphine to alleviate their symptoms.
Now most babies only stay in hospital for a few days under a new approach called Eat, Sleep, Console. These young patients stay in private rooms where they can bond with their parents and volunteer caregivers. The usual treatment is no longer prolonged therapy with opioid substitutes. Instead, mothers are encouraged to stay the night and learn to soothe their babies by swaddling, rocking and cooing them.
As a result, the average length of stay for neonates with neonatal abstinence syndrome (NAS) fell from 12 days to 6 days. Morphine use decreased by 79%, from 2.25 to 0.45 mg/kg per stay, according to the results of a quality improvement pilot project in one of the community hospitals in Atrium.
Similar findings at other hospitals nationwide have led to widespread adoption of Eat, Sleep, Console since its advent in 2017. That year, according to federal data, seven newborns were diagnosed with NAS per 1,000 births.
Proponents say the family-centered model helps parents feel less stigmatized and more confident in their ability to care for their babies, who may exhibit symptoms such as irritability and difficulty feeding for long periods of time. month.
The approach “really empowers families to do what they do best, which is to take care of each other,” said Douglas Dodds, MD, a pediatrician who led the effort at Atrium. Medscape Medical News.
Questioning old protocols
Many state perinatal collaborations, hospital associations, and health systems claim the program is the new standard of care for infants with NAS and neonatal opioid withdrawal syndrome (NOWS).
Twenty-six hospitals have adopted Eat, Sleep, Console as part of a National Institutes of Health-sponsored clinical trial and program called Advancing Clinical Trials in Neonatal Opioid Withdrawal Syndrome (ACT NOW). Researchers are comparing the approach to prior care protocols with respect to 12 outcomes, including medical readiness time to discharge, frequency of opioid replacement therapy, and safety issues, such as seizures during discharge. treatment.
The transition was quick. Less than a decade ago, most hospitals used the Finnegan Neonatal Abstinence Scoring System, which was developed in the 1970s to assess babies whose mothers had used heroin during pregnancy.
The Finnegan Score involves monitoring babies every 3 hours for 21 symptoms, including high-pitched crying, sneezing, gastrointestinal problems and yawning. If a baby rolls an 8 or higher three times in a row, most protocols using the traditional Finnegan approach recommend that providers move infants to a NICU, where they receive morphine or methadone. Once the opioid substitution therapy has started, the protocols provide for gradual weaning that lasts 3 to 4 weeks.
As the opioid epidemic grew and NICUs across the country began to fill with babies with NAS or NOW, some clinicians began to question the Finnegan-centric approach.
You have these miserable babies going through this really difficult experience, and our first step is to separate them from their mothers.
“You have these miserable babies going through this really difficult experience, and our first decision is to separate them from their mothers,” said Matthew Grossman, MD, pediatric hospitalist at Yale New Haven Children’s Hospital, New Haven, Connecticut, who created Manger , Sleep, Comfort.
Grossman, an associate professor and vice chair of quality in the Yale School of Medicine’s Department of Pediatrics, said he noticed that when mothers spent the night with their babies, infants tended to have fewer withdrawal symptoms. Indeed, previous studies had demonstrated the benefits of breastfeeding and allowing mothers and babies to share a room.
“If you think of mom as medicine, you can’t put the baby in a unit where mom can’t be there,” Grossman said. Medscape Medical News. “It would be like taking a child with pneumonia and putting them in a unit that has no antibiotics.”
Despite its importance, the Finnegan score has never been validated to guide the treatment of NAS. Additionally, Finnegan’s scores can be inconsistent, and the assessment requires disturbing an infant to check for signs such as his startle reflex, which, as Grossman and his fellow researchers have pointed out, goes against the recommendations from the American Academy of Pediatrics to prioritize swaddling. and minimize stimulation for infants with NAS.
On the other hand, Eat, Sleep, Console offers a simplified evaluation. Interventions are needed if a baby eats less than an ounce of food at a time / does not breastfeed, sleeps less than an hour at a time, or takes more than 10 minutes to be comforted. After trying non-pharmacological interventions, doses of drugs are used as needed. Babies who are well can be discharged in as little as 4 days.
Eliminate prejudice against parents with substance use disorders
Even with the promise of shorter stays and better care, the shift to nonpharmacological care presents hurdles for hospitals. Among these is the lack of physical space for mothers to share a room with their baby in a quiet environment.
“In many community hospitals, the only place infants go is a neonatal intensive care unit, outside of the nursery,” said Stephen Patrick, MD, MPH, associate professor and director of the Center for Child Health Policy at Vanderbilt University. School of Medicine, Nashville, which studies the stigma associated with opioid use during pregnancy.
Administrators at SSM St. Mary’s Hospital in St. Louis were initially hesitant to provide private rooms for mothers and babies with NAS and NOWS, according to Kimberly Spence, MD, neonatologist at SSM Health. She said the original plan was to place the babies in a busy, well-lit nursery.
But resistance waned when the hospital convinced health plans to pay for private rooms for the 5 to 7 days it typically takes a baby to go through weaning, said Spence, an associate professor of pediatrics at the St. Louis University School of Medicine, Missouri.
“We were able to provide enough data that this is evidence-based medicine and that babies are better off with their mothers, and that from an ethical point of view this is the good thing to do, to reduce transfers to a neonatal intensive care unit,” she said.
In addition, news stories about the family-centered approach and shorter stays for infants, as well as SSM’s launch of an outpatient clinic to treat pregnant women with opioid use disorders, helped the system attract more patients and increase its market share, Spence said.
Another challenge, according to Grossman and others, was getting doctors and nurses to overrule any judgments of parents with substance abuse disorders.
“A lot of faculty and staff on the medical team didn’t think we should trust moms with the medical care of their babies” at SSM, Spence said.
Some hospitals provide anti-bias training to teach providers that drug addiction is a disease that deserves proper medical treatment and not a patient’s moral failing. Such education may involve explaining that baby outcomes are improved when women are on methadone or buprenorphine treatment during pregnancy, even though using these drugs poses a risk of NAS.
Creating a system that supports parents with substance abuse disorders can help change perceptions. At Atrium Health, some staff members now enjoy working with these families because they can have a profound impact, Dodds said. He said they learned that families with substance abuse disorders “are not that different from other families.”
Dodds, Patrick, Spence and Grossman reported no relevant financial relationships.
Mary Chris Jaklevic is a medical journalist in the Midwest.
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