Hospitals should establish a clear weaning protocol for all potential pharmacotherapy treatments of neonatal abstinence syndrome (NAS) rather than relying on individual approaches that are likely to yield patient outcomes and experiences that are highly variable.
Overview
Why we are recommending this best practice
Regardless of the treatment opioid chosen, newborns receiving protocol-based weans experience a significantly shorter duration of opioid treatment (17.7 vs. 32.1 days, P < .0001) and shorter hospital stay (22.7 vs. 32.1 days, P = .004).
Strategies for implementation
Collaborate with members of the care team to establish an acceptable weaning protocol for all pharmacologic therapies for NAS. Some hospitals may consider weaning opioid doses q24-48 hours if meeting criteria; others may wean as rapidly as 10% up to three times a day.
Special Consideration
We do not recommend routine discharge of newborns while still weaning pharmacotherapy due to the evidence for longer length of pharmacotherapy exposure associated with this practice. However, we recognize that this strategy may be utilized in specific situations in which a well-established structure between the discharging hospital and the community PCP exists for close monitoring, strict follow-up criteria and prescription tracking are used, and the family is deemed reliable to follow-up.
While discharging home on outpatient pharmacotherapy decreases the initial hospital length of stay, outpatient NAS pharmacotherapy has been associated with longer length of treatment (60 vs. 19 days) and higher rates of emergency department utilization within 6 months of discharge compared to infants treated exclusively as inpatients.
References
References
- Maalouf FI, Cooper WO, Slaughter JC, Dudley J, Patrick SW. Outpatient pharmacotherapy for neonatal abstinence syndrome. J Pediatr 2018;199:151-157. https://www.ncbi.nlm.nih.gov/pubmed/29754866.
- Lai A, Philpot P, Boucher J, Meyer A. An outpatient methadone weaning program by a neonatal intensive care unit for neonatal abstinence syndrome. Popul Health Manag 2017 Oct;20(5):397-401. https://www-ncbi-nlm-nih-gov.laneproxy.stanford.edu/pubmed/28430046#.
References
- Hall ES, Wexelblatt SL, Crowley M, et al. A multicenter cohort study of treatments and hospital outcomes in neonatal abstinence syndrome. Pediatrics. 2014;134(2):e527-534.
- Hall ES, Wexelblatt SL, Crowley M, et al. Implementation of a neonatal abstinence syndrome weaning protocol: a multicenter cohort Study. Pediatrics. 2015;136(4):e803-810.
- Grossman MR, Berkwitt AK, Osborn RR, et al. An initiative to improve the quality of care of infants with neonatal abstinence syndrome. Pediatrics. 2017;139(6).
- Maalouf FI, Cooper WO, Slaughter JC, Dudley J, Patrick SW. Outpatient pharmacotherapy for neonatal abstinence syndrome. J Pediatr 2018;199:151-157. https://www.ncbi.nlm.nih.gov/pubmed/29754866.
- Lai A, Philpot P, Boucher J, Meyer A. An outpatient methadone weaning program by a neonatal intensive care unit for neonatal abstinence syndrome. Popul Health Manag. 2017 Oct;20(5):397-401. https://www-ncbi- nlm-nih gov.laneproxy.stanford.edu/pubmed/28430046#.