Opioid use and misuse in the United States is a substantial public health concern that does not spare pregnant individuals.  Recurrent opioid use during pregnancy may result in signs of opioid withdrawal, known as neonatal opioid withdrawal syndrome (NOWS), in the newborn infant. NOWS typically presents in the first few days after birth, as placentally-transferred opioids are cleared from the infant’s system. Clinical signs of NOWS include, but are not limited to, irritability, tremors, increased muscle tone, poor sleep, and poor feeding tolerance. This acute phase of opioid withdrawal requires careful medical monitoring and management by a health care provider.

The Finnegan Neonatal Abstinence Scoring Tool (FNAST) has been the traditional tool used to assess and manage infants with NOWS during the acute phase of opioid withdrawal. The FNAST has faced criticism for its subjectivity and tendency to overestimate the need for pharmacologic treatment.  The ESC care approach, a function-based approach, was developed to address concerns with the FNAST and has emerged as a promising alternative.

Research conducted by Lori Devlin, D.O. and colleagues evaluated the influence of the Eat, Sleep and Console (ESC) care approach on the length of hospital stay (LOS) and the duration and intensity of pharmacological treatment when compared to usual care with the FNAST in a group of pharmacologically treated infants enrolled in the Eating, Sleeping, and Consoling for Neonatal Opioid Withdrawal Syndrome (ESC-NOW) trial.  The results of this research were recently published in JAMA Pediatrics in an article entitled “Influence of Eat, Sleep, and Console on Infants Pharmacologically Treated for Opioid Withdrawal.”

Key findings:

1. Decreased opioid exposure after birth: Infants managed with the ESC care approach had lower total opioid exposure, with a substantial reduction in morphine milligram equivalents per kilogram (MME/kg) when compared with those receiving usual care.
2. Reduced duration of pharmacologic treatment: Infants in the ESC care approach group received fewer opioid doses and experienced a shorter duration of opioid treatment (6.3 days shorter).
3. Shorter hospital stays: The ESC care approach was associated with a significant decrease in the mean total length of hospital stay (6.2 days shorter), minimizing prolonged hospitalization for infants with NOWS.
4. Comparable peak opioid doses: Despite the longer time to initiation of pharmacologic treatment in the ESC care approach group, there were no significant differences in peak opioid doses between the two groups. “The ESC care approach was not associated with a higher peak opioid dose, although pharmacologic treatment was typically initiated later,” the study said, which shows that the ESC care approach does appropriately support infants during opioid withdrawal.

This study was supported by the National Institutes of Health (NIH) Environmental influences on Child Health Outcomes (ECHO) Program and the NIH’s Eunice Kennedy Shriver Institute of Child Health and Human Development (NICHD), funded through the NIH Helping to End Addiction Long-term® Initiative (HEAL).

Implications for clinical practice: 
These findings offer valuable insights for health care providers involved in the care of infants with NOWS:

• Optimized care approach: Implementing the ESC care approach is associated with improved hospital outcomes, including reduced opioid exposure and shorter hospital stays, without an increase in the severity of opioid withdrawal.
• Individualized management: The ESC care approach emphasizes nonpharmacologic interventions as first-line treatment, empowering caregivers to actively participate in infant care and decision-making.
• Early intervention: Early initiation of nonpharmacologic interventions is crucial in managing opioid withdrawal severity, potentially minimizing the need for pharmacologic treatment and its associated risks.

Conclusion:
The ESC care approach represents a significant advancement in the management of infants with NOWS, offering a comprehensive and effective alternative to traditional care methods. By focusing on the functional components of withdrawal and utilizing non-pharmacologic care as the first-line treatment, this approach improves hospital outcomes for all infants with NOWS.  Long-term neurodevelopmental follow-up in a population of infants from the ESC-NOW study, is being led by Dr. Devlin and colleagues.  The results of this follow-up will further inform the implementation of the ESC care approach in clinical practice, and will provide further insight on how to best enhance the well-being of infants and families affected by NOWS.