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Description
Abstract
OPTimize NOW
Thitinart Sithisarn, MD
Antenatal opioid exposure may result in neonatal opioid withdrawal syndrome (NOWS). Neonatal opioid
withdrawal is characterized by dysfunction in 3 primary areas: 1) the central nervous system, 2) the
autonomic nervous system and 3) the gastrointestinal system. Signs of withdrawal include but are not
limited to irritability, tremors, increased tone, hyperthermia, poor sleep, poor feeding, vomiting and
diarrhea. The natural history of NOWS is an initial increase in symptoms as placentally transferred
opioids are cleared from the infant’s system. With time, withdrawal symptoms will eventually abate. The
therapeutic focus is on the reduction of symptom severity, with a goal of ensuring normal infant growth
and development and maternal-infant bonding. A focus on a function-based approach to care in
addition to optimization of non-pharmacologic care, including a low stimulation environment,
swaddling, clustered care and the provision of mother’s own milk coupled, when possible, with infant
caregiver engagement to provide skin-to-skin care, and on demand breastfeeding has been shown to be
effective as first line treatment for infants with NOWS and is endorsed by the American Academy of
Pediatrics (AAP) [1].
If non-pharmacologic care alone does not mitigate the severity of opioid withdrawal, pharmacologic
treatment is indicated. The traditional approach to pharmacologic treatment for infants with NOWS is
initiation and escalation of opioid treatment until symptoms are controlled followed by a slow opioid
taper. This approach has been shown to be efficacious but is associated with extended opioid courses
and prolonged hospitalization, both of which have been associated with suboptimal developmental
outcomes. The use of pro re nata (PRN) or symptom-based dosing has been evaluated as a way to
decrease postnatal pharmacologic exposure for infants with NOWS. Conceptually, a PRN approach
would allow control of symptoms for infants who have severity of disease that borders on the usual
trigger for the extended treatment protocol. One to three doses of an opioid in such infants may be
enough to control symptoms sufficiently and allow for non-pharmacologic therapies to be the primary
mechanism for symptom control. This approach could avoid a prolonged course of treatment and
weaning for a subset of infants with milder disease, but as an emerging approach it has not been
validated. Quality improvement (QI) initiatives conducted in single centers and small regional
collaboratives have demonstrated a decrease in the duration of pharmacologic treatment and the length
of hospital stay with the use of a PRN (i.e., symptom-based) approach as compared to an opioid taper
approach. Improved short-term outcomes with a symptom-based dosing approach to pharmacologic
treatment have been noted in infants assessed and managed with either the Eat, Sleep, and Console
approach (ESC) or the Finnegan Neonatal Abstinence Assessment Tool (FNAST) [2-5]. In addition, the rate
of readmission within 30 days of hospital discharge, a balancing measure used in the QI initiatives, was
not increased with a symptom-based dosing approach when compared to a slow opioid taper.
Status | Active |
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Effective start/end date | 9/1/23 → 8/31/25 |
Funding
- Research Triangle Institute: $394,471.00
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Projects
- 1 Active
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OPTimize NOW - HEAL Evaluation of Limited Pharmacotherapies for Neonatal Opioid Withdrawal Syndrome (HELP for NOWS)
9/1/23 → 8/31/25
Project: Research project