Neonatal Abstinence Syndrome: Transitioning Methadone-Treated Infants from an Inpatient to an Outpatient Setting
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Journal of Perinatology (2012) 32, 425–430 r 2012 Nature America, Inc. All rights reserved. 0743-8346/12 www.nature.com/jp ORIGINAL ARTICLE Neonatal abstinence syndrome: transitioning methadone-treated infants from an inpatient to an outpatient setting CH Backes1, CR Backes2, D Gardner1, CA Nankervis1, PJ Giannone1 and L Cordero1 1Division of Neonatal-Perinatal Medicine, Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH, USA and 2College of Osteopathic Medicine, Ohio University, Athens, OH, USA Journal of Perinatology (2012) 32, 425–430; doi:10.1038/jp.2011.114; Objective: Each year in the US B50 000 neonates receive inpatient published online 18 August 2011 pharmacotherapy for the treatment of neonatal abstinence syndrome (NAS). The objective of this study is to compare the safety and efficacy of a Keywords: neonatal withdrawal; methadone treatment; outpatient traditional inpatient only approach with a combined inpatient and weaning outpatient methadone treatment program. Study Design: Retrospective review (2007 to 2009). Infants were born to mothers maintained on methadone in an antenatal substance abuse Introduction program. All infants received methadone for NAS treatment as inpatient. Methadone weaning for the traditional group (75 patients) was inpatient, Opioid dependence during pregnancy has significant implications whereas the combined group (46 patients) was outpatient. for the infant, most notably neonatal abstinence syndrome (NAS).1,2 NAS is a constellation of physiological signs and Result: Infants in the traditional and combined groups were similar in behaviors observed following in utero exposure to opiates.1,3 demographics, obstetrical risk factors, birth weight, gestational age (GA) Although the recreational and addictive use of opiates during and the incidence of prematurity (34 and 31%). Hospital stay was shorter pregnancy continues to receive more attention in the medical in the combined than in the traditional group (13 vs 25 days; P<0.01). community, prescription narcotic use among women of Although the duration of treatment was longer for infants in the childbearing age has increased significantly.4 Among exposed combined group (37 vs 21days, P<0.01), the cumulative methadone dose À1 infants, the incidence of NAS ranges from 21 to 94%, with about was similar (3.6 vs 3.1 mg kg , P ¼ 0.42). Follow-up information half of the infants requiring some form of pharmacotherapy.5–7 (at least 3 months) was available for 80% of infants in the traditional and In the United States, the number of drug affected newborns 100% of infants in the combined group. All infants in the combined group (including opiates) has increased 300% since the 1980s and the were seen p72 h from hospital discharge. Breastfeeding was more health care expenditure in their treatment has been estimated to be common among infants in the combined group (24 vs 8% P<0.05). as much as 112.6 million dollars per year.2,5 Much of this cost is Following discharge there were no differences between the two groups in because of prolonged hospital stays in neonatal intensive hospital readmissions for NAS. Prematurity (34 to 36 weeks GA) was the care units.7,8 only predictor for hospital readmission for NAS in both groups (P ¼ 0.02, The benefits of participating in an antenatal drug treatment OR 5). Average hospital cost for each infant in the combined group was program include a reduction in drug-seeking behavior, illicit $13 817 less than in the traditional group. substance abuse, preterm birth and infant mortality.9–12 Methadone Conclusion: A combined inpatient and outpatient methadone treatment use for narcotic-abusing women in an antenatal program improves in the management of NAS decreases hospital stay and substantially health care utilization and preparation for parenting responsibilities, reduces cost. Additional studies are needed to evaluate the potential long- although some continue to misuse illicit substances.13,14 term benefits of the combined approach on infants and their families. In clinical practice, NAS is commonly observed among infants born to mothers on methadone maintenance for opiate addiction.2,15 Traditional strategies for the care of infants with NAS Correspondence: Dr L Cordero, Division of Neonatal-Perinatal Medicine, Department of have focused mainly on inpatient management that has led to Pediatrics, College of Medicine, The Ohio State University Medical Center, N118 Doan Hall, prolonged hospital stays (that is, median of 25 days, range of 8 to 410 W. 10th Avenue, Columbus, Ohio 43210-1228, USA. 105 days).7,15–18 However, following initial stabilization, many E-mail: [email protected] Received 7 March 2011; revised 30 June 2011; accepted 11 July 2011; published online infants with NAS are otherwise healthy and may not require 11,13,18,19 18 August 2011 intensive inpatient care. Considering that prolonged Neonatal abstinence syndrome CH Backes et al 426 hospital stays limit opportunities for maternal–infant bonding and achieved 3 scores X8 or 2 scores X12. The dose was increased consume hospital resources, alternative strategies that reduce (0.025 to 0.05 mg kgÀ1 per dose, maximum dose 0.15 mg kgÀ1 unnecessary hospitalization are highly desirable.7,13,20–22 A recent per day) and the interval was changed to every 8 h if the national survey of the management of NAS in the United Kingdom withdrawal score remained >8. If NAS scores continued to be >12, and Ireland revealed that 29% of neonatal units discharge infants’ phenobarbital was added (10 mg kgÀ1 per load, 5 mg kgÀ1 per day home on medication.19 Other investigators reported no adverse maintenance). Non-pharmacological management, including events among infants with NAS administered medication by their swaddling, pacifier use and provision of a quiet environment, was caregivers in the community setting.23 However, the paucity of also used for both groups.21 available data on the safety, feasibility and resources required to care for infants with NAS on an outpatient basis has limited Traditional group: inpatient methadone weaning strategy widespread adoption of this approach. For infants in the traditional group methadone was decreased by These issues affecting the general medical community led to the 0.025 to 0. 05 mg kgÀ1 per dose every 3 days if the average development of a multidisciplinary combined inpatient and withdrawal score (in a 24-h period) remained <8. When the outpatient treatment program for infants with NAS. An attending maintenance dose was 0.05 mg kgÀ1 twice daily, the dosage physician (CRB) willing to care for these infants as outpatients interval was lengthened to once daily. NAS scores continued to be following initial inpatient stabilization offered this option to monitored and methadone was discontinued after 3 to 7 days of mothers in an antepartum substance abuse program. The purpose 0.05 mg kgÀ1 per day if the average score remained <8. Once the of this paper is to compare the safety and efficacy of a traditional infant was successfully weaned off methadone, an additional inpatient only approach vs a combined inpatient and outpatient 5- to 7-day period of monitoring for withdrawal was completed weaning strategy for infants with NAS. before discharge home. Following discharge infants in the traditional group were seen in primary care clinics and/or at a dedicated NAS clinic (Nationwide Children’s Hospital) where a Methods team of physicians, nurses, social workers, lactation specialists and This was a retrospective review conducted at The Ohio State physical/occupational therapists were available. University Medical Center between January 2007 and January 2009. This investigation was approved by the Institutional Review Board. Combined group: outpatient methadone weaning strategy Outpatient records (private physician, primary care clinics and To be included in the combined group infants and caregivers had emergency room) were also used. to fulfill specific medical and social work criteria (Figure 1). As a The Ohio State University Medical Center is a tertiary referral safeguard, only the amount of methadone needed for 3 days before center for obstetrics and gynecology, serving a population of the infant’s initial outpatient appointment was prescribed. All B9 00 000, with over 5000 births per year. We identified 244 caregivers underwent intensive instruction on administration of infants born to women receiving methadone as part of an methadone for their infants and were made aware of the symptoms antenatal outpatient treatment program. Of these infants 121 of drug overdose or withdrawal. Methadone was prescribed weekly (50%) required treatment for NAS. Infants exposed in utero to and dispensed from the hospital pharmacy in sealed, unit dose illicit drugs (that is, cocaine, heroin and so on) only were oral syringes. excluded. To ensure the validity of the maternal history provided, Following discharge infants in the combined group were seen in infants had a meconium or urine toxicology performed another dedicated outpatient clinic by the same physician (CRB) immediately after birth. that provided inpatient care. This clinic is staffed by trained nurses and had ancillary staff (social workers, lactation specialists and Initial inpatient management of NAS physical/occupational therapists) available for consultation. In the On the basis of attending physician preference, we have two outpatient clinic, a comprehensive evaluation of the infants’ treatment strategies for infants with NAS at our hospital. We general health (anthropomorphic data, physical examination) and identified 75 infants who received methadone for NAS entirely in state of abstinence using the Finnegan method was performed. the inpatient setting (traditional group) and 46 infants who When possible, scores were obtained immediately after feeding. initially received methadone treatment as inpatients then Caregivers were asked to keep records of their infants’ behaviors in completed the weaning process in the outpatient setting (combined the home setting and had 24 h access to their physician (CRB) to group). The initial hospital management of infants with NAS was immediately address any concerns.