‘Eat, Sleep, and Console’ method improves care of opioid-exposed newborns
Use of the novel quality improvement tool ‘Eat, Sleep, and Console’ (ESC) markedly reduced the length of hospitalization stay (LOS) and post-natal use of opiate medications in infants with in utero opioid exposure, according to data presented at PAS 2019.
“[O]ur goal … was to improve care of opioid-exposed newborns … using methods to adapt previously demonstrated successful approaches focusing on three things – simplified assessment of newborns experiencing opioid withdrawal, engaging and educating families in best practices to support their babies through drug withdrawal symptoms, and minimizing babies’ exposure to medications,” said study author Dr Susan Townsend from the University of Colorado School of Medicine in Denver, Colorado, US.
Opioid-exposed infants are conventionally managed using Finnegan scoring (FS) to evaluate signs of neonatal abstinence syndrome (NAS), a condition resulting from the sudden discontinuation of foetal exposure to substances received in utero, and serves as a guide to managing infants with NAS (ie, medication tapering). The family-centred ESC approach focuses on the comfort and care of infants with NAS. [Pediatrics 2014;134:e547-e561]
During the study, a multidisciplinary team had monthly meetings to direct the transition from FS to ESC, increase family involvement, and use morphine as needed instead of tapered methadone when necessary. Educational and charting tools and bedside teaching were used to guide the change in practice. [PAS 2019, abstract 3545.4]
Among the 635 newborns admitted to a single neonatal intensive care unit (NICU) during the pre-intervention period in 2017, 71 neonates had been exposed to opioids in utero. Of these, 46 received methadone for NAS, with an average LOS of 22.7 days.
From the first to the third quarter, LOS dropped from a median of 21.0 to 5.5 days.
The same period also saw a significant drop in medication use for NAS (from 75.0 percent to 27.8 percent), with the median length of medication exposure decreasing from 16.0 to 2.0 days.
Between January 1 and October 31, 2018, 43 out of 50 NICU infants who had foetal opioid exposure were discharged home.
A non-drug approach
The ESC approach focuses on non-pharmacologic supportive therapy (ie, proper feeding and soothing measures) to ensure that infants eat well (if unable to eat, a feeding tube may be considered), sleep undisturbed for at least an hour (may require holding the infant to induce sleep), and respond to consoling methods (eg, encouraging skin-to-skin contact). Morphine may be used should the calming techniques be ineffective. [Adv Neonatal Care 2019;19:138-144; A New Approach to NAS – Home in Six Days, http://www.nationalperinatal.org, accessed 6 May 2019]
The ESC method was proposed as an alternative to the traditional FS tool given the latter’s associated inconsistencies, as an initially low FS score may be high in succeeding evaluations due to interrater differences. Consequently, the high FS score might require pharmacologic intervention and eventually lead to increased LOS. [Advances in Neonatal Care, https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?videoId=32, accessed 6 May 2019]
Given the tremendous impact of the opioid epidemic on newborn care, implementing a care path that relies on non-pharmacologic interventions such as the ESC strategy can shorten hospital stays and reduce exposure to pharmacologic treatment, said Townsend.
“[ESC] was effective in reducing hospital stay for this large group of patients … Our philosophy is to ‘use hugs, not drugs’ in treating newborn opioid withdrawal symptoms,” said Townsend. “We are hopeful that this will provide long-term benefits to families and babies exposed to opioids. However, it remains to be seen whether there are other unintended consequences of this approach.”