With the opioid epidemic affecting many areas of our
country there has been a reported rise in opioid use during
pregnancy, which in turn has increased the incidence of neonatal
abstinence syndrome (NAS). When prescribed or illicit opioid medications are
used during pregnancy, the medications pass from the blood stream to the baby.
Once the baby is born he or she is no longer receiving the opioid
medications his or her mother was taking and begins the process of
withdrawal or neonatal abstinence syndrome. The Finnegan Neonatal Abstinence
Scoring System (FNASS), developed in 1975, is the most commonly used assessment
tool to determine the extent of withdrawal in an infant exposed to opioids
in utero. The FNASS focuses on the withdrawal symptoms of the infant
and treatment is based on scores derived from the tool. When the
scores fall with-in a certain range, morphine is initiated to assist with
diminishing the withdrawal symptoms. With the increase in the incidence
of NAS there has been new research and evidence that shows using a novel
approach to assessing and managing infants with NAS, called the Eat Sleep
Console (ESC) approach, will decrease the need for pharmacologic intervention
and decrease the average length of stay.
New Evidence in the Care of
Infants with Neonatal Abstinence Syndrome
Neonatal abstinence syndrome (NAS) was first described
in the literature in the 1970s by Dr. Loretta Finnegan (McQueen & Murphy-Oikonen, 2016).
“The neonatal abstinence syndrome refers to a postnatal opioid withdrawal
syndrome that can occur in 55 to 94% of newborns whose mothers were addicted to
or treated with opioids while pregnant” (McQueen & Murphy-Oikonen, 2016, p.
2469). It is…”a constellation of neurologic, gastrointestinal, and
musculoskeletal disturbances associated with withdrawal” (Grossman, Lipshaw, Osborn, &
Berkwitt, 2018, p. 2). “The incidence of NAS in the United States has
increased almost fivefold from 1.2 per 1000 births in 2000 to 5.8 per 1000
births in 2012” (Grossman et al.,
2018, p. 2). “Neonates exposed to opioids including heroin, prescription
painkillers, and opioid replacement therapy agents such as methadone and
buprenorphine, are now being born in all corners of the United States and
around the world” (Grossman,
Seashore, & Holmes, 2017, p. 226).
The Finnegan Neonatal Abstinence Scoring System (FNASS) is the
most widely used tool for assessing and managing the care of infants with NAS.
“With this tool, infants are assessed by 21-items divided in to three
categories: central nervous system disturbances,
metabolic/vasomotor/respiratory disturbances and gastrointestinal disturbances”
(Grossman et al., 2017, p. 227).
Many hospitals use a modified version of the FNASS tool, which
is used to assess the withdrawal symptoms of the infant and according to
criteria, determines when to start an infant on morphine to decrease the
withdrawal symptoms and increase comfort for the
infant. “The FNASS has been used to guide the management of
infants with NAS since its development in the mid-1970s, but despite its wide
acceptance, it has never been validated nor have its widely used score cutoffs
been tested” (Grossman et al.,
2018, p. 2). Therefore, a “sacred cow” and nursing practice that is
worth questioning is the continued use of the FNASS for the assessment and
management of infants with NAS.
P:Infants with neonatal abstinence syndrome (NAS)
I: Assessment and management using the Eat Sleep Console (ESC)
C: Assessment and management using the Finnegan Neonatal
Abstinence Scoring System
O: When the ESC approach is used to assess and manage infants with
NAS, they are
treated less frequently with morphine and the average length of
stay (ALOS) is also
In infants with NAS, does being assessed and managed
using the Eat Sleep Console (ESC) approach decrease the need for
pharmacologic intervention and decrease the ALOS as compared to infants
with NAS being assessed and managed using the Finnegan Neonatal
Abstinence Scoring System (FNASS)?
There is new research and evidence that has shown that using
a functional assessment for assessing and managing infants with
NAS drastically decreases the need for pharmacologic intervention and
decreases the ALOS. The researchers at Yale New Haven Children’s
Hospital created a novel assessment approach called the Eat Sleep Console
(ESC) approach that focuses on how the infant functions rather than on
the withdrawal symptoms of the infant (Grossman et al., 2018). They
discontinued the use of FNASS scores to guide pharmacologic management on the
inpatient unit and developed their own functional assessment that focused
on 3 simple parameters: the infant’s ability to eat, to sleep, and to be
consoled (Grossman et al., 2017).
“If the infant was able to breastfeed effectively or to take ?1 oz from a
bottle per feed, to sleep undisturbed for ?1 hour, and, if crying, to be
consoled within 10 minutes, then morphine was neither started nor increased
regardless of other signs of withdrawal. If the infant did not meet these
criteria, staff first attempted to maximize non-pharmacologic interventions; if
these attempts were unsuccessful, morphine was initiated or increased” (Grossman et al., 2017, p. e3).
The ESC approach was used as part of a 5-year quality improvement
project that lead to a decrease in pharmacologic treatment from 98%
to 12% and a decrease in ALOS from 22.5 to 5.9 days (Grossman et al., 2018) “The ESC
approach helps to shift the goal from reducing withdrawal signs at the expense
of exposure to additional opioids and other medications to a focused approach
aimed at the overall well-being of the infant” (Grossman et al., 2018, p. 5).
It focuses on the normal behaviors of the infant (eating, sleeping and the
ability to be consoled) and uses non-pharmacologic interventions as the
first line treatment, such as a quiet dark environment, rooming-in, swaddling,
on-demand feedings, rocking and holding. Parents were told that they were the
treatment for their infant and were expected to care for and be present as much
as possible (Grossman et al.,
2017). Support and coaching on the care of their infant
was provided to the parents by the nurses and physicians (Grossman et al., 2017).
The study suggested that using the ESC approach exposed
significantly fewer infants to pharmacologic treatment than if they had used
the FNASS approach (Grossman et
al., 2018). By using the FNASS to guide treatment they would have
exposed 25 additional infants to opioid therapy, an increase of 516% (Grossman et al., 2018). The infants
also had a substantially shorter ALOS than infants in most previous
reports without any significant adverse events or re-admissions (Grossman et al., 2018).