1. Neonatal Abstinence Syndrome
Larry Leeman MD MPH Mary Beth Sutter, MD
NM Perinatal Collaborative 3/31/17

2. Copyright © 2012 American Medical Association. All rights reserved.
Epidemic of maternal opiate use
Antepartum maternal opiate use increased from 1.19 (95% CI, ) to 5.63 (95% CI, ) per 1000 hospital births per year (P <.001) from 2000 to 2009
Neonatal Abstinence Syndrome and Associated Health Care Expenditures:  United States,
JAMA 2012; 307(18)
Copyright © 2012 American Medical Association. All rights reserved.

3. NAS epidemiology NAS 6 per 1000 births in 2013 in US
>1 baby born per hour
In New Mexico 8.5 per 1000 births in 2013, rising at 1.5% per year
Average hospital admit cost >$50,000
Average hospital transfer cost $5000-$7000 per baby
In literature NAS treatment rate 50% with in utero subutex or methadone exposure
JAMA. 2012;307(18)
Ko et al, Incidence of Neonatal Abstinence Syndrome- 28 states, MMRW 2016;65:

4. Copyright © 2012 American Medical Association. All rights reserved.
Epidemic of Neonatal Abstinence Syndrome
Neonatal abstinence syndrome increased from (95% CI, ) to 3.39 (95% CI, ) per 1000 hospital births per year (P <.001) from 2000 to 2009
Neonatal Abstinence Syndrome and Associated Health Care Expenditures:  United States,
JAMA 2012; 307(18)
Copyright © 2012 American Medical Association. All rights reserved.

5. Screening/ Observation
Have a policy on who is screened, or screen everyone
Maternal urine, infant urine, meconium
Symptom onset at hrs, depends on half life of substance
Consider other diagnoses in differential (sepsis, hypoglycemia, hypocalcemia, hyperthyroidism, HIE, SSRI exposure)
Hamdan AH et al. Neonatal Abstinence Syndrome Workup. Medscape 2016.

6. Evaluation Scoring with Finnegan’s Developed in 1975 22 items
Average normal newborn of 2, with 95th percentile of 7
No studies on efficacy, comparing methods
Can’t eat, can’t sleep, can’t soothe approach
Zimmerman-Baer et al. Finnegan neonatal abstinence scoring. Addiction 2010;105:524-8.

7. Modified Finnegan’s Neonatal Abstinence Scoring Tool.
Modified Finnegan’s Neonatal Abstinence Scoring Tool. Adapted from ref 101.
Hudak ML et al. Neonatal Drug Withdrawal. Pediatrics 2012;129:e

8. Holmes AV et al.Rooming-In to Treat Neonatal Abstinence Syndrome: Improved Family-Centered Care at Lower Cost.Pediatrics. 2016;137(6)

9. Holmes AV, Atwood EC, Whalen B, et al
Holmes AV, Atwood EC, Whalen B, et al. Rooming-In to Treat Neonatal Abstinence Syndrome:Improved Family-Centered Care at Lower Cost. Pediatrics. 2016

10. Pharmacologic Treatment
Purpose of treatment is to prevent seizures, promote growth, feeding, bonding
Opiate monotherapy superior- Cochrane Review
No data for one opiate over another
Co-therapy with phenobarbital or clonidine very limited role
Hudak ML et al. Neonatal Drug Withdrawal. Pediatrics 2012;129:e

11. Non-pharmacologic Treatment
Low stimuli, cluster care
Physical therapy, massage, skin-to-skin
Breastfeeding
If mothers stable on MAT
Decreases need for medication
Rooming-in
Decreases need for medication and transfers of care
Allows family to bond and participate in care
Abrahams RR, et al. Rooming-in compared with standard care. Canadian Fam Phys 2007;53:

12. Non-pharmacologic care by domain for the infant affected by NAS
J Addict Med September 1; 2(3): 113–120.

13. Follow up plan
Consider referral to CYFD for any + UDM on admission in mother or baby, or make a policy
Multidisciplinary care and collaboration
Mother: Maternity care, substance abuse care, contraception
Baby: Pediatrics care, developmental support/ early intervention, hepatitis C screening in late infancy
Support of father or other family members for substance abuse
Ongoing social work support

15. Sources:
US: Weighted national estimates from HCUP Nationwide Inpatient Sample (NIS), 2000, Agency for Healthcare Research and Quality (AHRQ), based on data collected by individual States and provided to AHRQ by the States. Total number of weighted discharges in the U.S. based on HCUP NIS = 36,417,565.
New Mexico and Rio Arriba: 2012 Hospital Inpatient Discharge Data (HIDD).

16. Phase 1 Goals To improve care of infants with NAS around the state
To empower sites to keep and treat babies when capable
To improve the transfer process when necessary
Surveyed 27 sites providing maternity care in NM on current practices and desires for training on NAS

17. Phase 1- Survey
Level of neonatal care offered at each facility and gestational age cutoff
Estimated number of infants with NAS each month
Availability of care for opiate addicted women
Screening methods/policies of mothers and infants
Number of hospitals electing to deliver NAS infants
First line pharmacologic agent for transfer and/or treatment, and availability/use of alternative or adjunct agents
Dyad care
Interested in additional training: care vs. transfer

18. Phase 1- Results Sites divided into low and high volume naturally
Most common concern was Finnegan’s tool use among staff
Many sites not rooming-in if there is a level 2/3/4 nursery
All but one site used morphine for treatment

19. Phase 1-Results Division of groups Deliver, diagnose, and transfer
Treat at delivery hospital
Intended for groups who will recognize and transfer

20. What did we learn? Many hospitals with relatively low volume
Most want additional training in either assessment/care or assessment/transfer for NAS babies
Morphine is predominant pharmacological treatment
Rooming in appears uncommon
Unable to assess breastfeeding by survey methodology
Lack numbers of opiate exposed babies or babies with NAS w/o pharmacological treatment

21. Phase 2 One time site-visit
Grand rounds presentation and discussion on next steps with interested small group
Intended for delivery, diagnose, and transfer groups
Mini- Sabbatical project
3-5 days at UNM in intensive clinical observation and one on one teaching with experts
Intended for groups providing treatment at their site

22. Phase 2
Socorro
In partnership with Envision for webnars and quality improvement project
Minisabbaticals; UNM, Espanola Pres, other sites?
Applying for grant with DOH for maternal opioid intervention
Silver City
Minisabbatical UNM in May
Meet with Perinatal Committee planned
Other sites
IHS-?GIMC or other site
Santa Fe

23. Phase 3- Future Collaboration with Envision
Quality improvement assessment at Socorro
Web modules accessible state wide
Teleconference for ongoing teaching and case questions
Exploring collaboration with ECHO for statewide series on Opioid use in pregnancy with maternal focus . Forum for discussing cases

24. Challenges
Develop services for areas with low numbers of opiate exposed infants
Inadequate capacity of NM’s rural maternity care, primary care and substance abuse retreatment
Increase access of pregnant women with opioid use disorder to prenatal care and treatment including Medication Assisted Treatment with buprenorphine and methadone
Determine assessment measures: # of infants diagnosed with NAS, # infants requiring pharmacological treatment, proportion of women with opioid dependence receiving treatment and prenatal care, proportion of NAS infants with rooming in and/or breastfeeding, proportion requiring NICU admission