P0585 - Evaluation and Treatment of Opiate vs. Polysubstance Exposed Infants in the Era of Eat, Sleep, Console

Background/Purpose: Opioid use among pregnant women has been on the rise since the early 2000s, with an increased incidence of neonatal abstinence syndrome (NAS) from 4.8 to 7.0 cases per 1000 births from 2012-2016. In addition to exposure to opiates-alone, many infants are exposed to multiple substances which has long been suggested to worsen withdrawal symptoms. Historically, evaluation and treatment has been guided by Finnegan Neonatal Abstinence Scoring System (FNASS) which focuses on the presence of withdrawal symptoms to guide the initiation of pharmacotherapy. At our institution, a new treatment approach called “Eat, Sleep, Console” (ESC) focuses on functional wellbeing of the infant and optimizes non-pharmacologic interventions prior to initiation of pharmacotherapy. Our aim was to investigate the previously suggested increased length of stay (LOS), severity of withdrawal, and use of pharmacotherapy in polysubstance exposed infants (PSE infants) compared to solely opiate exposed infants (OE infants) at our institution. Severity of withdrawal was measured using FNASS and ESC criteria and was compared between the two groups and correlated with those who received pharmacologic treatment.

Methods: We performed retrospective chart reviews of 470 infants born at greater than 35 weeks who were evaluated for NAS between January 2014-April 2020 on the general pediatric floor and newborn nursery at our children’s hospital. Patients were separated into two groups: PSE infants (exposed to a long acting opioid plus at least 1 other substance based on toxicology results) and OE infants. Utilization of morphine, LOS, and the number of infants meeting FNASS vs ESC criteria for initiating pharmacotherapy were compared between the two groups.

Results: PSE infants were treated with morphine significantly less, in 20% of cases compared to 50% in OE infants. PSE infants had a significantly shorter average LOS at 6.8 days than OE infants at 10.2 days. There was no statistically significant difference in the fraction of infants that met FNASS criteria requiring morphine between the two groups. However, PSE infants treated with morphine met ESC criteria more often when compared to the opioid-only group.

Conclusion: While there has been a longstanding belief that PSE infants will demonstrate worsened withdrawal symptoms and require escalation of care, our study shows these infants require less pharmacotherapy and have shorter LOS in comparison to OE infants. Interestingly, PSE infants who received pharmacologic treatment met ESC criteria more often than OE infants. This highlights the increased severity of withdrawal affecting function in PSE infants that is evident when evaluated by ESC criteria, a potential advantage of this criteria vs FNASS. Additionally, the decreased pharmacotherapy use in PSE infants may be a result of optimization of non-pharmacologic interventions and improved recognition of non-opioid related withdrawal symptoms with ESC, a topic not previously explored in other sources.