The Rising Burden of NAS

The opioid epidemic has led to a steady rise in NAS cases among newborns over the past three decades. Currently, around 2% of infants born in hospitals develop NAS, with a new diagnosis occurring approximately every 15 minutes. An article in the New England Journal of Medicine noted that from 2004 to 2013, the proportion of neonatal intensive care unit (NICU) days attributed to NAS surged from 0.6% to 4%.

The financial implications of NAS are staggering, imposing a considerable burden on healthcare systems and families alike. By 2014, the annual cost to taxpayers via public insurance exceeded $400 million. A study evaluating 23 hospitals reported that from 2013 to 2016, the average length of hospital stays for NAS-afflicted infants was 19 days, costing roughly $37,584 each, in stark contrast to the average of three days and $3,536 for newborns with other medical issues.

The emotional toll of NAS is also profound, affecting not only the infants but also their caregivers, particularly mothers. Opioids encompass a variety of forms, both illicit and prescribed, spanning from injectable heroin to pain management medications like hydrocodone and addiction treatments such as methadone. A pregnant woman’s use of opioids can stem from various circumstances, which does not necessarily reflect a lack of concern for her unborn child.

A Distressing Introduction

Let’s rewind another five years to 2011. During my initial year of residency in the NICU, I vividly remember the piercing cries of a newborn suffering from NAS for the first time. These infants often exhibit a range of symptoms, including heightened sensitivity, muscle stiffness, poor feeding ability, frequent sneezing, sleep disturbances, elevated caloric needs due to a fast metabolism, diarrhea, temperature fluctuations, and even seizures.

At that time, the conventional approach to treating NAS involved administering opioid medications—typically liquid morphine or methadone. The prevailing belief was that replenishing the opioids would alleviate withdrawal symptoms, gradually tapering the dosage until the infant was completely weaned off the treatment.

Due to the inherent communication barriers between infants and healthcare providers, symptom-based scoring systems were developed to assess withdrawal severity. With the diverse range of NAS symptoms, these scoring tools became rather intricate.

Origins of a Scoring System

Introduced in 1975, the Finnegan Neonatal Abstinence Scoring System (FNASS), named after Dr. Loretta Finnegan, became the predominant method for evaluating NAS patients. My hospital utilized this 21-point scoring system in 2011, where infants were assessed every three hours based on various NAS-related factors, including sleep patterns, tremors, feeding difficulties, nasal congestion, yawning, sneezing, irritability, and perspiration.

Protocols based on Finnegan scores guided decisions regarding adjustments in medication, such as methadone doses. My hospital prided itself on adhering to the latest protocols to enhance infant comfort and reduce hospital stays.

Despite efforts to optimize this protocol-driven approach, I frequently found myself caring for infants for 20 days or more. Middle-of-the-night calls requesting methadone dose increases due to rising Finnegan scores were not uncommon. I often heard the distressed cries of the infant in the background, realizing that a mere yawn or sneeze could trigger a score increase warranting a dosage adjustment.

Families faced heartbreaking news when informed that they could not take their child home for an additional two or three days because we had to pause the weaning process. Like many colleagues, I pondered whether there might be a more effective way to support these infants and their families.

Identifying the Flaws

I began to discern flaws in our methodology. Notably, I observed abrupt fluctuations in Finnegan scores during nursing shift changes. This was not due to any intentional manipulation but rather highlighted the subjective nature of the scoring system. Distinguishing between mild and moderate symptoms proved challenging.

Additionally, FNASS lacked specificity. While certain symptoms like yawning or sneezing were prevalent in infants with NAS, they were not exclusive to this condition.

Despite believing we employed the most advanced and evidence-based scoring system and weaning protocol, I realized that improvement was not the answer—it was time for a complete overhaul.

A Transformative Message

Fast forward to 2016: Matthew Grossman, MD, a pediatric hospitalist at Yale New Haven Children's Hospital, stood before the crowded conference hall. He too had utilized traditional methods for treating NAS but eventually began implementing changes. Grossman captivated his audience, emphasizing a message that felt as though it had been waiting to be discovered.

He challenged the status quo, asking why we continued with established methods. The answer, Grossman suggested, was rooted in tradition. He likened the situation to enhancing a boat's speed by merely adding more sails—true progress required a fundamental shift in approach.

A Fresh Perspective

Grossman and his team proposed a straightforward premise: infants require three essential needs—eating, sleeping, and being consoled (ESC). These needs were easily measurable, and the focus shifted away from symptoms. They monitored NAS infants, assessing their ability to consume one ounce of milk (or breastfeeding equivalent), sleep for an hour, or be comforted within ten minutes. Medication was reserved for instances where these needs were unmet.

This new model transformed treatment. Instead of rigidly tapering opioid doses, morphine was administered as needed. Infants were no longer isolated in the NICU; they remained with their families. The focus shifted to natural comforting methods—breastfeeding, skin-to-skin contact, swaddling, dim lighting, and minimizing stimulation. Instead of adhering to strict feeding schedules, babies were allowed to feed on demand.

Grossman shared remarkable results from implementing the ESC model over two years. The average hospital stay for 287 NAS patients dropped from 22 to just 6 days. Morphine usage plummeted from 98% to 14%, and costs decreased from $44,824 to $10,289. No adverse events were reported.

Spreading the ESC Approach

Upon returning from the conference, I was eager to introduce the ESC model in my hospital in Montana. Fortunately, I didn’t have to wait long. My colleague, neonatologist Allison Rentz, MD, was also aware of ESC and led our hospital in becoming an early adopter the following year. Rentz described her initial reaction to Grossman’s work: “The dramatic improvements in reducing length of stay and need for morphine were evident everywhere it was implemented—no negatives.”

Our facility also launched a volunteer cuddler program for NAS infants lacking family support to hold and comfort them. Although the program is currently paused due to the Covid-19 pandemic, prior to this, we received over 400 applications for just 30 positions.

The ESC model has rapidly spread across the nation. The protocol developed by the Yale group was replicated at Boston Medical Center, which created a toolkit distributed through the Colorado Perinatal Care Quality Collaborative and further shared with us. Rentz recalls, “We had educational materials, templates for parents, and training modules for nurses. It felt like we had everything we needed handed to us, which is typically rare for a smaller state like this.”

Demonstrated Success

Prior to adopting ESC, our hospital had managed to reduce the average length of stay for NAS patients to about 12 days, considered acceptable within the FNASS framework. The introduction of ESC revolutionized our process: according to Rentz, stays decreased to four to five days.

Other institutions experienced similar successes with ESC. Boston Medical Center reported a 35% reduction in length of stay and a 54% decrease in pharmacological treatments, while the University of North Carolina's health system noted a 52% reduction in length of stay and a 79% decline in medication use. ESC principles have now been embraced in at least 25 states and counting.

Revisiting the Nine Dots

The development and dissemination of ESC would not have been possible without Dr. Grossman’s innovative problem-solving approach. Recall the nine-dot puzzle? Solving it necessitates thinking beyond conventional limits. As Grossman articulated in a 2019 article in Hospital Pediatrics, it entails recognizing that there is no box at all.

In managing NAS, we had inadvertently confined ourselves to outdated practices, following the herd without questioning. Ultimately, someone would unveil the confines of this unnecessary construct. After this realization, Grossman contemplated its implications for other pediatric medical fields.

He remarked, “Boxes exist throughout medicine. For instance, neonatal jaundice is a common issue, yet we often medicalize normal processes.” He pointed out the lack of evidence supporting the thresholds pediatricians use to determine when phototherapy for jaundice is necessary, emphasizing the need to differentiate between pathological conditions and natural variations.

I posed a similar question to Rentz, who identified constraints surrounding nasogastric (NG) feeding. Some premature infants may struggle with sucking and swallowing, necessitating NG tube placement for adequate nutrition. There is currently a movement to establish home NG feeding programs, empowering parents to provide care safely at home and reducing hospital stays.

Physicians pledge to prioritize patient safety, often erring on the side of caution, especially with vulnerable populations. My hope is that as scientific understanding evolves, it will clarify when conditions such as NAS, neonatal jaundice, or dysphagia require aggressive intervention versus when nature should be allowed to take its course with minimal interference.

The first video titled "When babies are born withdrawing from opioids" explores the complexities of NAS and the challenges faced by affected infants and their families.

The second video titled "Revolutionizing Opioid and Trauma Treatment with Neurostimulation" discusses innovative approaches to treating opioid dependence and related traumas, emphasizing the evolution of treatment methodologies.