Eat, Sleep, Console model for neonatal opioid withdrawal syndrome: a meta-analysis.

Background: The rising incidence of drug abuse among pregnant women has rendered neonatal opioid withdrawal syndrome a significant global health concern. Methods: Databases including PubMed, Web of Science, the Cochrane Library, Embase, Elton B. Stephens. Company (EBSCO), China National Knowledge Infrastructure (CNKI), and Wanfang were searched for comparative studies of the Eat, Sleep, Console model vs. traditional assessment tools for neonatal opioid withdrawal syndrome. Two reviewers conducted literature searches, screened according to the inclusion criteria, extracted data, and independently verified accuracy. All meta-analyses were conducted using Review Manager Version 5.4. Results: In total, 18 studies involving 4,639 neonates were included in the meta-analysis. The Eat, Sleep, Console model demonstrated superior outcomes in assessing neonatal opioid withdrawal syndrome, significantly reducing the need for pharmacological treatment [risk ratio = 0.44, 95% confidence interval (CI) = 0.34-0.56, P < 0.001], decreasing the length of hospital stay [standard mean difference (SMD) = -2.10, 95% CI = -3.43 to -0.78, P = 0.002], and shortening the duration of opioid treatment (SMD = -1.33, 95% CI = -2.22 to -0.45, P = 0.003) compared to the Finnegan Neonatal Abstinence Scoring System. Conclusions: The Eat, Sleep, Console model is more effective than the Finnegan Neonatal Abstinence Scoring System in improving the assessment and management of neonatal opioid withdrawal syndrome.

Neonatal Abstinence Signs during Treatment: Trajectory, Resurgence and Heterogeneity.

Neonatal abstinence syndrome (NAS) presents with a varying severity of withdrawal signs and length of treatment (LOT). We examined the course and relevance of each of the NAS withdrawal signs during treatment in a sample of 182 infants with any prenatal opioid exposure, gestational age ≥ 35 weeks, without other medical conditions, and meeting the criteria for pharmacological treatment. Infants were monitored using the Finnegan Neonatal Abstinence Scoring Tool. Daily mean Finnegan scores were estimated using linear mixed models with random subject effects to account for repeated withdrawal scores from the same subject. Daily item prevalence was estimated using generalized estimating equations with a within-subject exchangeable correlation structure. The median LOT was 12.86 days. The prevalence of withdrawal signs decreased from day one to day three of treatment. However, certain central nervous system (CNS) and gastrointestinal (GI) signs showed sporadic increases in prevalence notable around two weeks of treatment, accounting for increases in Finnegan scores that guided pharmacotherapy. We question whether the resurgence of signs with a prolonged LOT is mainly a consequence of opioid tolerance or withdrawal. Monitoring CNS and GI signs throughout treatment is crucial. Future studies directed to better understand this clinical phenomenon may lead to the refining of NAS pharmacotherapy and perhaps the discovery of treatment alternatives.

Independent Impact of Eat, Sleep, Console Assessment on Neonatal Opioid Withdrawal Syndrome.

Compared with the Finnegan Neonatal Abstinence Scoring System (FNASS), the Eat, Sleep, Console (ESC) approach reduces pharmacotherapy and length of stay (LOS) for neonatal opioid withdrawal syndrome (NOWS) infants. The independent outcome contribution of ESC is unknown as the approach combines ESC assessment with additional management changes. Our objective was to evaluate ESC assessment's independent impact on outcomes compared with FNASS. We conducted a retrospective cohort study of in utero opioid-exposed infants ≥35 weeks gestation managed with FNASS versus ESC. Outcomes included pharmacotherapy initiation, LOS, length of pharmacotherapy, and emergency department visit/readmissions. Among 151 FNASS and 100 ESC managed infants, pharmacotherapy initiation (P = .47), LOS for all infants (P = .49), and LOS for pharmacologically treated infants (P = .68) were similar. Length of pharmacotherapy did not differ (P = .84). Emergency department evaluation/NOWS readmission was equally rare (P = .65). Using equivalent models of care, comparison of ESC and FNASS assessment tools showed no difference in NOWS outcomes.

Physiologic dysregulation in newborns with prenatal opioid exposure: Cardiac, respiratory and movement activity.

BACKGROUND: Newborns with prenatal opioid exposure (POE) are commonly diagnosed with neonatal abstinence/opioid-withdrawal syndromes due to characteristic symptoms and overt behaviors. However, little is known about the underlying physiology of opioid-exposed newborns. OBJECTIVE: Cardiac, respiratory and movement activity were measured to identify physiologic dysregulation and quantify pathophysiologic instabilities of the central and autonomic nervous systems in POE newborns. METHODS: In this pilot study, 30 hospitalized POE newborns (>35 wks gestational age) participated in one of two study phases wherein physiologic activity was measured for an 8-10 h session. In Phase 1, 17 infants received usual treatment to provide a general assessment of physiologic activity. In Phase 2, 13 infants participated in an interventional study (NCT02768844) using a prototype mattress that delivered stochastic vibratory stimulation (SVS). Changes in physiologic activity were compared for device on (N) and off (F) for three interfeed periods (FNF or NFN). RESULTS: Phase 1 showed that although infants' heart rate was on average within normal newborn range (mean 137 bpm, SD 7), infants were tachycardic 16% of the study period and tachypneic (mean 74 breaths/min, SD 13) 62% of the period. Infants moved 33% of the period; 17% were durations >30 s. In Phase 2, heart rate, respiratory rate, movement duration and frequency were each reduced for SVS N compared to SVS F in the FNF protocol (P < 0.05). CONCLUSION: Findings support that physiologic measures can identify dysregulation not captured with current withdrawal scoring assessments. Larger studies are warranted to assess if mattress SVS helps regulate pathophysiologic instabilities in infants with POE.

Improving the Assessment of Neonatal Abstinence Syndrome (NAS).

Neonatal Abstinence Syndrome (NAS) is a public health problem of epidemic proportions. The Finnegan Neonatal Abstinence Scoring System (FNASS) is the tool most widely used to evaluate NAS. However, it is limited by its lack of interrater reliability and standardized approach. Surveys to evaluate the FNASS were distributed to nurses at the Women and Infants Hospital in Providence, RI, USA. Infants (n = 78) treated for NAS and born to methadone-maintained mothers were examined to compare items administered from the FNASS and the NICU Network Neurobehavioral Scale (NNNS). All nurses reported that the FNASS was somewhat to very subjective. More than half reported that it was somewhat to not accurate and a new scoring method is needed to accurately diagnose NAS. Correlations between FNASS items and NNNS items showed 9 of 32 (28.1%) correlations were strong (rs > 0.5), 5 of 32 (15.6%) were moderate (0.3 < rs < 0.5), and 10 of 32 (31.3%) were weak (0.1 < rs < 0.3). Principal component factor analysis (PCA) of the NNNS explained more variance (35.1%) than PCA of NNNS and FNASS items combined (33.1%). The nursing survey supported the need for developing a more objective exam to assess NAS. NNNS exam items may be used to improve the evaluation of NAS.

Judging the Neonatal Abstinence Syndrome Assessment Tools to Guide Future Tool Development: The use of Clinimetrics as Opposed to Psychometrics.

In the face of the current Neonatal Abstinence Syndrome (NAS) epidemic, there is considerable variability in the assessment and management of infants with NAS. In this manuscript, we particularly focus on NAS assessment, with special attention given to the popular Finnegan Neonatal Abstinence Score (FNAS). A major instigator of the problem of variable practices is that multiple modified versions of the FNAS exist and continue to be proposed, including shortened versions. Furthermore, the validity of such assessment tools has been questioned, and as a result, the need for better tools has been suggested. The ultimate purpose of this manuscript, therefore, is to increase researchers' and clinicians' understanding on how to judge the usefulness of NAS assessment tools in order to guide future tool development and to reduce variable practices. In short, we suggest that judgment of NAS assessment tools should be made on a clinimetrics viewpoint as opposed to psychometrically. We provide examples, address multiple issues that must be considered, and discuss future tool development. Furthermore, we urge researchers and clinicians to come together, utilizing their knowledge and experience, to assess the utility and practicality of existing assessment tools and to determine if one or more new or modified tools are needed with the goal of increased agreement on the assessment of NAS in practice.