Management of Neonatal Opioid Withdrawal Syndrome with Eat, Sleep, Console: a systematic review and meta-analysis & Engagement and adherence with recommended developmental follow-up among infants with intrauterine opioid exposure

Abstract

With the rise of the opioid epidemic across the United States, the rate of newborns affected by intrauterine opioid exposure, developing Neonatal Opioid Withdrawal Syndrome (NOWS), has almost doubled in the last decade, from 4.0 per 1000 birth hospitalizations in 2010 to 7.8 per 1000 in 2017. Infants who are diagnosed with NOWS have longer and more complicated birth hospitalizations, associated with increased healthcare expenditure and strain on families. The most commonly used treatment approach relies on a lengthy and impractical numerical scoring system, the Finnegan Neonatal Abstinence Scoring System, that has been used to determine cutoffs for pharmacological treatment initiation to manage withdrawal symptoms. In recent years, a function-based approach with a focus on non-pharmacological treatment has gained traction by limiting the assessment to the infant’s ability to perform its basic physiologic functions: to Eat, Sleep and Console (ESC). The ESC approach has been implemented in many centers across the U.S as part of quality improvement initiatives that report improved newborn outcomes, with decreased length of hospitalization and pharmacological treatment. These reports alone lack the methodological robustness to assess the effect of ESC on newborn outcomes and provide clear recommendations for management of NOWS. In Paper 1, we address this gap with a systematic review of the literature and meta-analysis to assess the effect of ESC approach for management of NOWS in the short-term outcomes, compared to standard treatment based on a version of FNASS. The pediatric care for infants who were exposed to opioids in utero is not limited to the period of the birth hospitalization. Children with a history of opioid exposure are at higher risk for neurodevelopmental abnormalities, behavioral diagnoses, as well as lower cognitive and academic performance. In light of these concerns, opioid-exposed infants are recommended to have increased surveillance during the first years of life and engage in state-level Early Intervention (EI) services and hospital-based Developmental Follow-up (DFU) clinics, that conduct formal developmental assessments and provide tailored interventions to address the infant’s needs. However, there is lower adherence to standard pediatric care visits in this population and the engagement in the two recommended developmental services is mostly unknown. Furthermore, the factors that promote successful engagement of opioid-exposed infants in these interventions have not yet been identified. In Paper 2, we describe the engagement and adherence to the recommended developmental surveillance services in a retrospective cohort, as well as report the maternal, infant and pediatric care characteristics associated with higher engagement.