AbstractWith the opioid epidemic affecting many areas of ourcountry there has been a reported rise in opioid use duringpregnancy, which in turn has increased the incidence of neonatalabstinence syndrome (NAS). When prescribed or illicit opioid medications areused 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 opioidmedications his or her mother was taking and begins the process ofwithdrawal or neonatal abstinence syndrome. The Finnegan Neonatal AbstinenceScoring System (FNASS), developed in 1975, is the most commonly used assessmenttool to determine the extent of withdrawal in an infant exposed to opioidsin utero. The FNASS focuses on the withdrawal symptoms of the infantand treatment is based on scores derived from the tool.
When thescores fall with-in a certain range, morphine is initiated to assist withdiminishing the withdrawal symptoms. With the increase in the incidenceof NAS there has been new research and evidence that shows using a novelapproach to assessing and managing infants with NAS, called the Eat SleepConsole (ESC) approach, will decrease the need for pharmacologic interventionand decrease the average length of stay.New Evidence in the Care ofInfants with Neonatal Abstinence Syndrome Neonatal abstinence syndrome (NAS) was first describedin the literature in the 1970s by Dr. Loretta Finnegan (McQueen & Murphy-Oikonen, 2016).”The neonatal abstinence syndrome refers to a postnatal opioid withdrawalsyndrome that can occur in 55 to 94% of newborns whose mothers were addicted toor treated with opioids while pregnant” (McQueen & Murphy-Oikonen, 2016, p.
2469). It is..
.”a constellation of neurologic, gastrointestinal, andmusculoskeletal disturbances associated with withdrawal” (Grossman, Lipshaw, Osborn, &Berkwitt, 2018, p. 2). “The incidence of NAS in the United States hasincreased almost fivefold from 1.2 per 1000 births in 2000 to 5.8 per 1000births in 2012” (Grossman et al.,2018, p.
2). “Neonates exposed to opioids including heroin, prescriptionpainkillers, and opioid replacement therapy agents such as methadone andbuprenorphine, are now being born in all corners of the United States andaround the world” (Grossman,Seashore, & Holmes, 2017, p. 226).The Finnegan Neonatal Abstinence Scoring System (FNASS) is themost 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 threecategories: 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, whichis used to assess the withdrawal symptoms of the infant and according tocriteria, determines when to start an infant on morphine to decrease thewithdrawal symptoms and increase comfort for theinfant. “The FNASS has been used to guide the management ofinfants with NAS since its development in the mid-1970s, but despite its wideacceptance, it has never been validated nor have its widely used score cutoffsbeen tested” (Grossman et al.
,2018, p. 2). Therefore, a “sacred cow” and nursing practice that isworth questioning is the continued use of the FNASS for the assessment andmanagement of infants with NAS. PICO QuestionP:Infants with neonatal abstinence syndrome (NAS)I: Assessment and management using the Eat Sleep Console (ESC)approachC: Assessment and management using the Finnegan NeonatalAbstinence Scoring System (FNASS)O: When the ESC approach is used to assess and manage infants withNAS, they are treated less frequently with morphine and the average length ofstay (ALOS) is also decreased In infants with NAS, does being assessed and managedusing the Eat Sleep Console (ESC) approach decrease the need forpharmacologic intervention and decrease the ALOS as compared to infantswith NAS being assessed and managed using the Finnegan NeonatalAbstinence Scoring System (FNASS)? There is new research and evidence that has shown that usinga functional assessment for assessing and managing infants withNAS drastically decreases the need for pharmacologic intervention anddecreases the ALOS. The researchers at Yale New Haven Children’sHospital created a novel assessment approach called the Eat Sleep Console(ESC) approach that focuses on how the infant functions rather than onthe withdrawal symptoms of the infant (Grossman et al.
, 2018). Theydiscontinued the use of FNASS scores to guide pharmacologic management on theinpatient unit and developed their own functional assessment that focusedon 3 simple parameters: the infant’s ability to eat, to sleep, and to beconsoled (Grossman et al., 2017).”If the infant was able to breastfeed effectively or to take ?1 oz from abottle per feed, to sleep undisturbed for ?1 hour, and, if crying, to beconsoled within 10 minutes, then morphine was neither started nor increasedregardless of other signs of withdrawal. If the infant did not meet thesecriteria, staff first attempted to maximize non-pharmacologic interventions; ifthese 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 improvementproject 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 ESCapproach helps to shift the goal from reducing withdrawal signs at the expenseof exposure to additional opioids and other medications to a focused approachaimed 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 theability to be consoled) and uses non-pharmacologic interventions as thefirst line treatment, such as a quiet dark environment, rooming-in, swaddling,on-demand feedings, rocking and holding. Parents were told that they were thetreatment for their infant and were expected to care for and be present as muchas possible (Grossman et al.,2017). Support and coaching on the care of their infantwas provided to the parents by the nurses and physicians (Grossman et al., 2017).
The study suggested that using the ESC approach exposedsignificantly fewer infants to pharmacologic treatment than if they had usedthe FNASS approach (Grossman etal., 2018). By using the FNASS to guide treatment they would haveexposed 25 additional infants to opioid therapy, an increase of 516% (Grossman et al., 2018).
The infantsalso had a substantially shorter ALOS than infants in most previousreports without any significant adverse events or re-admissions (Grossman et al., 2018).