Matthew Grossman

An Initiative to Improve the Quality of Care of Infants With Neonatal Abstinence Syndrome

This quality improvement project demonstrated that interventions focused on nonpharmacologic care led to significant improvement in short-term outcomes for infants with NAS. BACKGROUND AND OBJECTIVES: The incidence of neonatal abstinence syndrome (NAS), a constellation of neurologic, gastrointestinal, and musculoskeletal disturbances associated with opioid withdrawal, has increased dramatically and is associated with long hospital stays. At our institution, the average length of stay (ALOS) for infants exposed to methadone in utero was 22.4 days before the start of our project. We aimed to reduce ALOS for infants with NAS by 50%. METHODS: In 2010, a multidisciplinary team began several plan-do-study-act cycles at Yale New Haven Children’s Hospital. Key interventions included standardization of nonpharmacologic care coupled with an empowering message to parents, development of a novel approach to assessment, administration of morphine on an as-needed basis, and transfer of infants directly to the inpatient unit, bypassing the NICU. The outcome measures included ALOS, morphine use, and hospital costs using statistical process control charts. RESULTS: There were 287 infants in our project, including 55 from the baseline period (January 2008 to February 2010) and 44 from the postimplementation period (May 2015 to June 2016). ALOS decreased from 22.4 to 5.9 days. Proportions of methadone-exposed infants treated with morphine decreased from 98% to 14%; costs decreased from

A Novel Approach to Assessing Infants With Neonatal Abstinence Syndrome

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Neonatal Abstinence Syndrome: Time for a Reappraisal

10 289. No infants were readmitted for treatment of NAS and no adverse events were reported. CONCLUSIONS: Interventions focused on nonpharmacologic therapies and a simplified approach to assessment for infants exposed to methadone in utero led to both substantial and sustained decreases in ALOS, the proportion of infants treated with morphine, and hospital costs with no adverse events.

Neonatal abstinence syndrome management: A review of recent evidence

OBJECTIVES Neonatal abstinence syndrome (NAS) is a growing problem and poses a significant burden on the health care system. The traditional Finnegan Neonatal Abstinence Scoring System (FNASS) assessment approach may lead to unnecessary opioid treatment of infants with NAS. We developed a novel assessment approach and describe its effect on the management of infants with NAS. METHODS We retrospectively compared treatment decisions of 50 consecutive opioid-exposed infants managed on the inpatient unit at the Yale New Haven Childrens Hospital. All infants had FNASS scores recorded every 2 to 6 hours but were managed by using the Eat, Sleep, Console (ESC) assessment approach. Actual treatment decisions made by using the ESC approach were compared with predicted treatment decisions based on recorded FNASS scores. The primary outcome was postnatal treatment with morphine. RESULTS By using the ESC approach, 6 infants (12%) were treated with morphine compared with 31 infants (62%) predicted to be treated with morphine by using the FNASS approach (P < .001). The ESC approach started or increased morphine on 8 days (2.7%) compared with 76 days (25.7%) predicted by using the FNASS approach (P < .001). There were no readmissions or adverse events reported. CONCLUSIONS Infants managed by using the ESC approach were treated with morphine significantly less frequently than they would have been by using the FNASS approach. The ESC approach is an effective method for the management of infants with NAS that limits pharmacologic treatment and may lead to substantial reductions in length of stay.

The Utility of Inpatient Rebound Bilirubin Levels in Infants Readmitted After Birth Hospitalization for Hyperbilirubinemia

The opioid abuse problem in the United States has grown into an epidemic, with an estimated 2.5 million Americans currently dependent on heroin or prescription pain medications.1 One of the many consequences of this growing public health crisis has been a marked increase in the number of infants born to mothers who used opioids during pregnancy. The rate of neonatal abstinence syndrome (NAS), the syndrome of withdrawal these infants may suffer after birth, quintupled from 2000 to 2012.2 Often, these infants occupy NICU beds for weeks or even months.3 Despite these skyrocketing numbers, long lengths of stay, and an enormous strain on the medical system, our standard management of these infants has remained largely unchanged for decades. With a critical reappraisal of our current approach and an eye toward innovation, we can alter our entire paradigm for managing infants with NAS and create opportunities for significant improvements in both patient outcomes and health care expenditures. The current approach used by many institutions for the management of NAS has its roots in a study published >40 years ago. In 1975, the Finnegan Neonatal Abstinence Scoring System (FNASS) was developed and is now widely accepted as the primary tool to assess infants with NAS. The FNASS is a 21-item tool that lists signs of withdrawal and assigns a point value to …

Buprenorphine for the Neonatal Abstinence Syndrome.

BACKGROUND The evaluation and management of infants with neonatal abstinence syndrome (NAS), the constellation of opioid withdrawal specific to newborns, have received renewed attention over the past decade during a new epidemic of opioid use, misuse, abuse, and dependence. Infants with NAS often endure long and costly hospital stays. OBJECTIVE We aim to review recent literature on the management and outcomes of infants with, and at risk for, opioid withdrawal. METHODS We reviewed articles indexed in PubMed over the past 5 years that examined interventions and/or outcomes related to the management of infants with NAS. Thirty-seven studies were included in our review comprising 8 categories: 1) identification of infants at risk for NAS, 2) prenatal factors, 3) evaluation of signs and symptoms, 4) non-pharmacologic care, including rooming-in and breastfeeding, 5) standardization of traditional protocols, 6) pharmacologic management, 7) alternative treatment approaches, and 8) long-term outcomes. RESULTS Non-pharmacologic interventions, standardization of traditional protocols, and alternative treatment approaches were all associated with improved outcomes. Lengths of stay were generally lowest in the studies of non-pharmacologic interventions. Patients exposed to buprenorphine in utero tended to have better short-term outcomes than those exposed to methadone. Longer-term outcomes for infants with NAS appear to be worse than those of control groups. CONCLUSION The current epidemic necessitates both continued research, and the application of new evidence-based practices in the assessment and treatment of newborns exposed to opioids in utero. Projects focused on non-pharmacologic interventions appear to hold the most promise.

Cognitive Bias in Inpatient Pediatrics

BACKGROUND AND OBJECTIVES There are few data evaluating the role of inpatient rebound bilirubin levels in the management of infants readmitted after their birth hospitalization for indirect hyperbilirubinemia. The goal of the present study was to evaluate the clinical utility of inpatient rebound bilirubin levels within this patient population. METHODS A retrospective cohort study was conducted of 226 infants readmitted after their birth hospitalization for indirect hyperbilirubinemia. Data from 130 infants with rebound bilirubin levels drawn at a mean of 6.1±2.4 hours after discontinuation of phototherapy were compared with data from 96 infants without rebound bilirubin levels. The primary outcome was readmission to the hospital, and secondary outcomes included length of stay and discharge time. A subgroup analysis compared characteristics of children who required repeat phototherapy versus those who did not. RESULTS Overall, 5 of 130 patients from the rebound group were readmitted compared with 4 of 96 patients from the no-rebound group (P=.98). Length of stay was significantly longer for patients with rebound bilirubin levels (27.7 vs 23.2 hours; P=.001). Patients with bilirubin levels lowered to ≤14 mg/dL were less likely to receive repeat phototherapy than those with levels>14 mg/dL (2 of 129 vs 12 of 97; P=.001). CONCLUSIONS Early inpatient rebound bilirubin levels do not successfully predict which patients will require hospital readmission for repeat phototherapy. Children with bilirubin levels lowered to ≤14 mg/dL with phototherapy are unlikely to receive repeat phototherapy.

Quality improvement initiative to improve inpatient outcomes for Neonatal Abstinence Syndrome

To the Editor: Kraft et al. (June 15 issue)1 report that in the Blinded Buprenorphine or Neonatal Morphine Solution (BBORN) trial, the duration of treatment in infants with the neonatal abstinence syndrome was shorter with buprenorphine than with morphine. I am concerned that these findings do not account for the likely effects of 30% ethanol in their standard buprenorphine solution. Ethanol is a well-known facilitator of the γ-aminobutyric acid receptor, and its inclusion (one assumes to facilitate the stability of the solution) may have had an effect on the outcome of the trial. It seems to me that Kraft et al. clearly showed the superiority of buprenorphine in 30% ethanol to morphine in water.

Is It Time to Stop Classifying Febrile Infants With Positive Urinalyses as High-Risk for Meningitis?

The contribution of cognitive bias toward diagnostic error has been well documented.1–7 Previous research exploring the effects of these cognitive pitfalls centers on examples from internal and emergency medicine, but it is fair to presume that pediatric hospitalists remain equally vulnerable to such cognitive error.8 To improve the overall awareness of cognitive bias within inpatient pediatrics, we present 2 cases that serve to illustrate some of the many cognitive biases a pediatrician may encounter in inpatient practice. We conclude with strategies to avoid the effects of cognitive bias on diagnostic accuracy. A 3-year-old male with no significant medical history presented to the emergency department (ED) with 11 days of a limp and 10 days of fever. His review of systems was otherwise positive for intermittent abdominal pain, increased loose stool, and a 3-pound weight loss. On examination, he had no point tenderness or swelling or erythema over either extremity; results of his neurologic examination were normal. The patient’s laboratory work was significant for a white blood cell count of 18.9 × 103/ μ L, hemoglobin of 10.8 g/dL, erythrocyte sedimentation rate of 65 mm/h, and C-reactive protein of 51.5 mg/L. Given the patient’s fever, limp, and elevated inflammatory markers, the inpatient team began an evaluation for osteomyelitis. A bone scan was positive in the area of the left lateral femoral condyle, and a follow-up MRI revealed inflammatory changes in the medial femoral metaphysis and epiphysis. He was diagnosed with osteomyelitis and was discharged from the hospital on intravenous antibiotics. Two weeks later, the patient presented with worsening abdominal pain, loose stool, and continued elevation in his inflammatory markers. A colonoscopy was performed and revealed evidence of Crohn’s disease. On review, the inflammatory changes seen previously on the MRI were consistent with chronic recurrent multifocal …

Walking a Tightrope: Balancing the Risk of Diagnostic Error in Inpatient Pediatrics

ObjectivesTo improve Neonatal Abstinence Syndrome (NAS) inpatient outcomes through a comprehensive quality improvement (QI) program.DesignInclusion criteria were opioid-exposed infants ≥36 weeks. QI methodology including stakeholder interviews and plan-do-study-act (PDSA) cycles were utilized. We compared pre- and post-intervention NAS outcomes after a QI initiative that included: A non-pharmacologic care bundle, function-based assessments consisting of symptom prioritization and then the “Eat, Sleep, Console” (ESC) Tool; and a switch to methadone for pharmacologic treatment.ResultsPharmacologic treatment decreased from 87.1 to 40.0%; adjunctive agent use from 33.6 to 2.4%; hospitalization length from a mean 17.4 to 11.3 days, and opioid treatment days from 16.2 to 12.7 (p < 0.001 for all). Total hospital charges decreased from