Impact of Eat, Sleep, Console versus Finnegan Assessment Tool for Neonatal Opioid Withdrawal Syndrome in a Mother-baby Couplet Care and Neonatal Intensive Care Unit Setting

Background: The national opioid crisis has led to increased fetal opioid exposure and a subsequent surge in neonatal opioid withdrawal syndrome (NOWS). The Eat Sleep Console (ESC) function-based assessment tool has been shown to reduce the percentage of infants requiring pharmacotherapy and decrease length of stay (LOS) compared to the Finnegan Neonatal Abstinence Scoring System (FNASS). However, most studies evaluated the ESC tool as a component of a larger non-pharmacologic care bundle involving parental rooming-in and a low stimulation environment in Pediatric inpatient units. Many US hospitals with delivery services do not have Pediatric units. It is unknown whether the ESC approach would have a similar impact in hospitals where NOWS infants are cared for in mother-baby couplet care and those requiring pharmacotherapy are admitted to the high stimulation NICU environment. The objective of our study was to evaluate whether the ESC tool can safely reduce the need for pharmacologic treatment and decrease LOS compared to the FNASS approach in a couplet care/NICU environment.

Methods: Using a retrospective cohort design, we compared infants with perinatal exposure to methadone, buprenorphine, heroin or pain control opioids managed using FNASS to those managed after ESC assessment tool implementation. Subjects included infants born at ≥ 35 weeks gestational age at 6 Kaiser Permanente Northern California facilities between January 2018 and June 2021. NOWS treatment protocols remained consistent throughout the study period and focused on optimizing non-pharmacologic treatment. Primary outcomes were the percentage requiring pharmacotherapy and LOS. Secondary outcomes included length of pharmacotherapy (LOT) and ER visit/hospital readmission rates within 30 days following discharge. Multivariable logistic and Cox regression were used to adjust for possible baseline differences and/or confounders.

Results: We identified 264 infants with perinatal opioid exposure, 184 managed with FNASS and 80 managed with ESC. Demographic variables and withdrawal risk factors were similar between groups (Table 1). The proportion requiring pharmacotherapy was 20.7% with FNASS and 16.3% with ESC (p=0.4). The median LOS among all infants was 3.5 (IQR: 3-6.5) days with FNASS and 3.7 (IQR: 3-5.4) days with ESC (p=0.6). Among NOWS patients requiring pharmacotherapy, the median LOS was 14.4 (IQR: 12.2-20.2) days with FNASS versus 14.0 (IQR: 11.9-14.6) days with ESC (p=0.5) Median LOT did not differ between groups: FNASS 10 (IQR: 9-16) days vs ESC 9 (IQR: 9-12) days (p=0.8). ER visit/hospital readmission rates for NAS were similar at 1.1% and 2.5% among the FNASS and ESC groups, respectively (p=0.4). Primary and secondary outcomes were unchanged after adjustment (Table 2).

Conclusion: In centers where non-pharmacologic care in the mother-baby unit has been optimized and NOWS infants receive pharmacotherapy in the NICU, use of the ESC tool alone does not significantly reduce the initiation of pharmacotherapy nor decrease LOT or LOS.