OBJECTIVES: To compare pharmacologic treatment strategies for neonatal abstinence syndrome (NAS) with respect to total duration of opioid treatment and length of inpatient hospital stay. METHODS: We conducted a cohort analysis of late preterm and term neonates who received inpatient pharmacologic treatment of NAS at one of 20 hospitals throughout 6 Ohio regions from January 2012 through July 2013. Physicians managed NAS using 1 of 6 regionally based strategies. RESULTS: Among 547 pharmacologically treated infants, we documented 417 infants managed using an established NAS weaning protocol and 130 patients managed without protocol-driven weaning. Regardless of the treatment opioid chosen, when we accounted for hospital variation, infants receiving protocol-based weans experienced 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). Among infants receiving protocol-based weaning, there was no difference in the duration of opioid treatment or length of stay when we compared those treated with morphine with those treated with methadone. Additionally, infants treated with phenobarbital were treated with the drug for a longer duration among those following a morphine-based compared with methadone-based weaning protocol. (P ≤ .002). CONCLUSIONS: Use of a stringent protocol to treat NAS, regardless of the initial opioid chosen, reduces the duration of opioid exposure and length of hospital stay. Because the major driver of cost is length of hospitalization, the implications for a reduction in cost of care for NAS management could be substantial.

, on behalf of the OCHNAS Consortium abstract OBJECTIVES: To evaluate the generalizability of stringent protocol-driven weaning in improving total duration of opioid treatment and length of inpatient hospital stay after treatment of neonatal abstinence syndrome (NAS). METHODS:We conducted a retrospective cohort analysis of 981 infants who completed pharmacologic treatment of NAS with methadone or morphine from January 2012 through August 2014. Before July 2013, 3 of 6 neonatology provider groups (representing Ohio's 6 children's hospitals) directed NAS nursery care by using group-specific treatment protocols containing explicit weaning guidelines. In July 2013, a standardized weaning protocol was adopted by all 6 groups. Statistical analysis was performed to identify effects of adoption of the multicenter weaning protocol on total duration of opioid treatment and length of hospital stay at the protocol-adopting sites and at the sites with preexisting protocol-driven weaning.RESULTS: After adoption of the multicenter protocol, infants treated by the 3 groups previously without stringent weaning guidelines experienced shorter duration of opioid treatment (23.0 vs 34.0 days, P , .001) and length of inpatient hospital stay (23.7 vs 31.6 days, P , .001). Protocol-adopting sites also experienced a lower rate of adjunctive drug therapy (5% vs 21%, P = .004). Outcomes were sustained by the 3 groups who initially had specific weaning guidelines after multicenter adoption (duration of treatment = 17.0 days and length of hospital stay = 23.3 days).CONCLUSIONS: Adoption of a stringent weaning protocol resulted in improved NAS outcomes, demonstrating generalizability of the protocol-driven weaning approach. Opportunity remains for additional protocol refinement.WHAT'S KNOWN ON THIS SUBJECT: Use of a standard treatment protocol with stringent weaning guidelines for infants with neonatal abstinence syndrome supports improved outcomes including shorter duration of opioid exposure and length of hospital stay. WHAT THIS STUDY ADDS:We demonstrate generalizability of a protocol-driven weaning strategy for improvement in hospital outcomes for neonatal abstinence syndrome. After adoption, adherent protocol-adopting centers improved outcomes and eliminated differences in outcomes compared with centers with preexisting stringent weaning protocols.

High humidity high flow nasal cannula has become a widely used alternative for nasal continuous positive airway pressure for the treatment of apnea of prematurity. We describe our experience of one incident of subcutaneous scalp emphysema, pneumo-orbitis and pneumocephalus with concomitant use of the high-flow nasal cannula. Journal of Perinatology (2008) 28, 779-781; doi:10.1038/jp.2008 Case Baby W was a 26 weeks gestation male with a birth weight of 901 g. He was born to a 20-year-old gravida 1 para 1 mother through a spontaneous vaginal delivery. Pregnancy was complicated by premature labor. His mother received steroids and was treated with magnesium sulfate prior to delivery. Her Group b-streptococcus status was unknown, serology non-reactive, hepatitis B surface antigen negative and Rubella immune. Baby W received continuous positive airway pressure (CPAP) at delivery and was intubated at 15 min of life. One dose of surfactant was given at the time of initial intubation. Baby W remained ventilated until 20 days of life. At that time he was extubated to 4 l min À1 high humidity high flow nasal cannula. Baby W had a large patent ductus arteriosis (PDA) that was treated medically with two courses of Neoprofen. The PDA decreased in size to small-moderate with no clinically significant shunting and did not require surgical ligation. Baby W was weaned to 2 l min À1 high humidity high flow nasal cannula by 36 days of life. At that time, Baby W was noted to have scalp crepitis.Scalp crepitis was noted in the frontal, parietal and occipital regions of the scalp, extending to the temporal regions with swelling noted on the right greater than left. Baby W's right eye was swollen, no proptosis was noted and there was no discharge from either eye. Skull X-rays showed subcutaneous edema and swelling, with no fracture of the skull. A chest X-ray showed no pneumothorax or pneumomediastinum. Baby W's high flow nasal cannula was discontinued and he was placed under an oxygen hood. A computerized tomography scan of the head revealed free air in the orbits bilaterally, and under the scalp. An ophthalmologist evaluated Baby W and his exam revealed no compromise of the blood supply or the optic nerves. The ophthalmologist recommended continued treatment with the oxygen hood as needed for oxygenation and discontinuation of the nasal cannula. Baby W continued under the oxyhood for 22 days and was then weaned to room air.Baby W was clinically evaluated frequently over the next 48 h. The scalp crepitis resolved over that time, as did the scalp swelling and eye swelling. Because the clinical symptoms resolved with use of the oxyhood there were no further studies performed. Baby W was discharged at a weight of 2266 g and at 75 days of life. He was not on oxygen at the time of discharge and had no further recurrence of scalp crepitis or orbital swelling.

The public health crisis of pregnant women being exposed to drugs of abuse and of its impact on their unborn children continues to grow at an alarming rate globally. The state of pregnancy is unique, with physiological changes that can lead to changes in the way drugs are handled by the body in both pharmacokinetics and response. These changes place the pregnant woman, fetus, and newborn infant at risk, as many of these drugs can cross the placenta and into breast milk. The substances most commonly linked to harmful effects include alcohol, tobacco, cannabis, stimulants, and opioids. The pharmacological and toxicological changes caused by in utero exposure or breastfeeding exposure are difficult to study, and the full extent of the mechanisms involved are not fully understood. However, these changes can significantly affect the risks of substance abuse and influence optimal treatment of pregnant women with a substance use disorder. In addition, newborns who were exposed to drugs of abuse in utero can experience withdrawal syndromes. Pharmacological management in infants is used to guide and treat withdrawal symptoms, with the goal being to improve the infant's sleep, eating, and comfort. Several barriers may prevent pregnant women from seeking help for substance use, including stigma and interactions with the legal system. Understanding changes in pharmacology, including pharmacokinetic changes that happen during pregnancy, is essential for anticipating the extent of maternal exposure and neonatal adverse effects.