Pharmacologic Treatment and Length of Hospitalization for Neonatal Abstinence Syndrome (NAS) in an Open Bay Neonatal Intensive Care Unit (NICU) Using Novel Non-Pharmacologic Interventions

doi:10.21203/rs.3.rs-3432822/v1

Objective

Evaluate effectiveness of a novel horizontal rocking bassinet for the management of neonatal abstinence syndrome (NAS).

Study Design:

Prospective cohort study of infants ≥ 35 weeks admitted to an open bay neonatal intensive care unit (NICU) for NAS. Three patient subsets analyzed: controls/Group 1, structured non-pharmacologic interventions (NPI)/Group 2, and structured NPI including the novel bassinet/Group 3.

Results

Group 3 had significant increases in length of stay (LOS) compared to Group 1 (p = 0.006) and Group 2 (p = 0.013). Group 3 had significantly higher length of treatment (LOT) than Group 1 (p = .041). Group 3 had significantly higher total mg/kg morphine exposure than Group 1 (p = .006).

Conclusion

The novel bassinet was not effective as a NPI based on LOS, LOT, and total mg/kg morphine exposure for NAS patients in this study. Further research is needed before novel bassinets are adopted for routine NAS care.

Scientific community and society/Scientific community/Ethics

Health sciences/Health care/Paediatrics

Treatment and care for infants with Neonatal Abstinence Syndrome (NAS) has historically involved medications such as morphine, clonidine, phenobarbital, and methadone. These drugs have concerning side-effects and are associated with prolonging hospitalization (1–7). As a result, non-pharmacological treatment for NAS has increasingly become a focus of care and has included interventions on environmental control, feeding methods, social integration, and soothing techniques (7–12). Commonly, environmental control has implied quiet, dimly lit single-patient rooms with minimal stimulation and supplemented by soothing techniques. Such environmental control is difficult in an open-bay neonatal intensive care unit (NICU).

In 2020, our academic, metropolitan medical center located in the Southeastern United States, received a 2019 facility summary for NAS from the state registry. Length of stay (LOS) for infants treated for NAS at our center was 22.6 days (range: 2–80 days) compared to the 12.0 day average statewide. Of the infants admitted to our hospital with concerns for NAS, 74% received pharmacologic therapy compared to 42% statewide. Thus, one area of focus was to research and clarify non-pharmacologic interventions (NPI) for infants presenting with NAS to lessen pharmacologic exposures and reduce LOS. The purpose of this study was to evaluate the implementation of a novel horizontal rocking bassinet in conjunction with NPI for the management of infants being pharmacologically treated for NAS in an open-bay NICU.

A prospective cohort study was performed involving infants ≥ 35 weeks gestation admitted to the NICU for pharmacologic treatment of NAS during 2019 (control group, Group 1), and from September 2021 to March 2023 (study groups, Groups 2 and 3). NAS patients admitted in 2020 were excluded based on extensive COVID-19 restrictions during that year. Infants with neurologic impairment not consistent with NAS withdrawal, evidence of having any significant congenital malformations, and infants receiving pharmacologic intervention for pain or sedation were also excluded. A Finnegan-based scoring protocol for pharmacologic treatment of NAS was and is followed in our NICU (13).

From a review of literature, we identified and implemented traditional NPI for infants with NAS (7–12). We elected to use the 5S’s (14) method for infant soothing. The 5S’s method for soothing infants was developed by pediatrician Harvey Karp in 1981 and consists of five techniques: swaddle, side-stomach position, shush, swing, and suck. We also identified specific NICU bed locations for NAS patients to better minimize noise and the intensity of light, incorporated the use of white noise, and increased availability of volunteers to hold infants in need of calming. These interventions were routinely utilized by August of 2021 with the first infant enrolled in Group 2 (traditional NPI) by September 2021. In February 2022, we entered our first infant with NAS into Group 3, which involved those NAS patients placed in the commercially available “novel” side-to-side horizontal rocking bassinet. The novel bassinet was equipped with a speaker that provided white noise and a sound sensor that detected noise made by the infant. Based on the infant’s noise and activity level, the novel bassinet responded by adjusting the side-to-side motion and the volume of the white noise.

Historic data on infants with NAS admitted to the NICU in 2019 was retrospectively obtained to serve as control comparisons to study populations. Prospective data was obtained on infants admitted to the NICU from September 2021 to March 2023 and served as study comparisons to controls.

Three subsets of patients were analyzed. Group 1 included infants (n = 39) pharmacologically treated for NAS in 2019 before the initiation of identified traditional NPI (Control Group). Group 2 included infants (n = 21) pharmacologically treated for NAS during 2021–2023 after the initiation of organized traditional NPI for NAS plus the 5S’s method for infant soothing. Group 3 involved those infants (n = 20) during 2021–2023 pharmacologically treated for NAS, who received the same organized traditional NPI as Group 2 but also by study protocol were placed in one of the novel bassinets. Informed consent was required for patient enrollment into the novel bassinet group (Group 3) but waived for those in Group 1 (Controls) and Group 2 (NPI). Infants enrolled in the novel bassinet group that also had other medical concerns were initially admitted to an open warmer and then transitioned to a novel bassinet once able to maintain their own temperature for at least 24 hours.

Infants in Group 3 were weaned from the novel bassinet 48 hours before pharmacologic treatment was discontinued using the following protocol:

Morphine dose 0.04 mg,
Place basinet in weaning mode (no motion but white noise). Continue swaddling and secure using sleep sack per the manufacturer's recommendations.
Once weaning mode tolerated (withdrawal scores return to baseline), move to standard open crib.
Once in standard open crib wrap with waffle weave blanket (facility’s standard of care)
Place separate white noise machine at the bedside.
NAS scoring continues during weaning process.
Educate parents/guardian on use of appropriate white noise in preparation for discharge.

Nursing Satisfaction Survey

Using a “train the trainer” approach, all nursing staff were trained on the 5S’s approach to soothing infants and on the manufacturer’s recommendations for use of the novel bassinet. Nurse satisfaction with the use of the novel bassinet was explored. A survey was created through SurveyMonkey, using the Delphi technique, to investigate nurse perceptions regarding the care of infants with NAS. Along with demographic questions, the survey explored nurse perceptions related to time spent consoling NAS infants and which devices/tools they thought were most effective in soothing infants. Nurses were sent a preamble and link to the survey via an online learning management system prior to the start of the novel horizontal rocking bassinet trial. Nurses consented to participate in the study by completing the survey A post-trial survey link was distributed at the close of the trial. Survey responses were anonymous.

Data Analysis

Descriptive analysis of infant demographic data was analyzed, and categorical data was reported as frequencies and percentages. Continuous data were reported as means and standard deviations. Shapiro-Wilk tests indicated the assumption of normality was violated for LOS, LOT, morphine, clonidine, crying, and sleeping. Levene’s statistic demonstrated homogeneity of variances, thus one-way ANOVA was conducted for LOS, LOT, clonidine, crying, and sleeping. Post hoc comparisons with one-way ANOVA used Scheffe’s test. Levene’s statistic demonstrated homogeneity of variances assumption was violated for morphine and non-parametric testing was used. (Table 1). Inferential analyses using one-way ANOVA determined differences between groups with follow-up post-hoc tests as applicable to LOS, LOT, morphine and clonidine exposure, crying, and sleeping using Finnegan scoring. Finnegan scores specific for crying and sleeping were analyzed for each infant group to assess differences in degree of agitation and sleep.

Table 1

*Inferential Analyses*
Variable	M	SD	n	F	P
Length of Stay (in days)
Treatment 1	32.26	15.98	39	6.398	0.003*
Treatment 2	31.76	11.94	21	-	-
Treatment 3	46.29	17.28	20	-	-
Length of Treatment (in days)
Treatment 1	28.18	16.48	39	3.993	0.022*
Treatment 2	27.38	10.98	21	-	-
Treatment 3	39.70	18.84	20	-	-
Clonidine (mg/kg)
Treatment 1	248.61	353.01	39	2.177	0.120
Treatment 2	174.39	203.66	21	-	-
Treatment 3	376.60	328.73	20	-	-
Crying (in Finnegan Scoring)
Treatment 1	1.92	0.453	39	0.582	0.561
Treatment 2	1.95	0.454	21	-	-
Treatment 3	2.03	0.054	20	-	-
Sleeping (in Finnegan Scoring)
Treatment 1	1.55	0.179	39	4.412	0.015*
Treatment 2	1.42	0.155	21	-	-
Treatment 3	1.48	1.141	20	-	-
	Median*	-	n	H	P
Morphine (mg/kg)
Treatment 1	5.22	-	39	7.485	0.024*
Treatment 2	7.24	-	21	-	-
Treatment 3	10.98	-	20	-	-
One-way ANOVA used for LOS, LOT, Clonidine, Crying, and Sleeping. M = mean; SD = standard deviation; * = p < .05, statistically significant result. Kruskal-Wallis Test used for Morphine. Median* = non-parametric testing

A Likert scale ranked from 1–5 (1 = not helpful; 5 = most helpful) was used for the nursing survey and assessed nurses’ perceptions of the novel bassinet in enhancing the quality of care and the ability to keep infants in a safe sleep position, lessen time spent consoling/soothing the infant, and reduce stress experienced during care of infants with NAS. Nurse participants were asked open-ended questions about challenges with providing care to NAS infants, suggestions for ways to improve care for these infants, challenges they encountered when using the novel bassinet, features of the bassinet they found helpful, and any changes they would suggest for the novel bassinet. Descriptive analysis of RN survey sample included age, race/ethnicity, education level, years as an RN, years working in the NICU, and years caring for infants with NAS (Table 2).

Table 2 Demographic data

Infant Characteristics	Group 1 N=39	Group 2 N=21	Group 3 N=20
Gestational Age, (weeks)	38.18	37.92	38.5
	M (SD)	M (SD)	M (SD)
Maternal Age, (years)	29 (4.39)	30.05 (4.63)	31.25 (4.80)
Birth weight, (g)	2913 (514.89)	2792.62 (505.10)	3057.2 (532.65)
Birth head circumference, (cm)	32.54 (1.53)	32.71 (1.46)	33.38 (2.24)
	M (Range)	M (Range)	M (Range)
APGAR Score 1 minute 5 minutes	7.77 (1-9) 8.69 (7-9)	7.75 (7-9) 8.55 (7.9)	7.25 (1-8) 8.2 (4-9)
	M (SD)	M (SD)	M (SD)
Therapeutic morphine total dose exposure, mg/kg	9.86 (9.94)	9.52 (7.79)	19.71 (21.72)
Therapeutic clonidine total dose exposure, mcg/kg	248.61 (353.01)	174.39 (203.66)	376.6 (328.73)
Discharge weight, (g)	3611.05 (742.93)	3403.33 (611.22)	4029.5 (841.30)
Discharge head circumference, (cm)	35.56 (2.04)	35.33 (1.76)	36.93 (2.11)
Length of hospitalization, days	32.26 (15.98)	31.76 (11.94)	46.29 (17.28)
Length of time in SNOO, days	N/A	N/A	34.25 (18.72)
Length of treatment, days	28.18 (16.48)	27.38 (10.97)	39.7 (19.83)
	n (%)	n (%)	n (%)
Race White Black	32 (82.05) 7 (17.95)	15 (71.43) 6 (28.57)	16 (80.00) 4 (20.00)
Ethnicity Non-Hispanic Gender Male Female	39 (100.00) 23 (58.97) 16 (41.03)	21 (100.00) 9 (42.86) 12 (57.14)	20(100.00) 12 (60.00) 8 (40.00)
C-section Scheduled Routine Emergent	13 (33.33) 0 (0.00) 2 (5.13) 11 (28.21)	12 (57.14) 4 (19.05) 5 (23.81) 7 (33.33)	6 (30.00) 1 (5.00) 1 (5.00) 4 (20.00)
Vaginal Delivery Spontaneous Operative/Vacuum	26 (66.67) 23 (58.97) 3 (7.69)	9 (42.86) 8 (38.10) 1 (4.76)	14 (70.00) 12 (60.00) 1 (5.00)
Exposed to maternal polysubstance use	38 (97.44)	19 (90.48)	20 (100.00)
Discharge disposition Parents Grandparents Other Relatives Foster Care Adopted	15 (38.46) 9 (23.08) 6 (15.38) 8 (20.51) 1 (2.56)	10 (47.62) 4 (19.05) 1 (4.76) 6 (28.57) 0 (00.00)	5 (25.00) 5 (25.00) 2 (10.00) 8 (40.00) 0 (00.00)

Note: g = grams; cm = centimeters; mg/kg = milligrams/kilogram; mcg/kg = micrograms/kilogram

The use of the novel basinet was discontinued in March 2023 after an interval review of LOT and LOS data.

Three subsets of patients were analyzed with respect to NPI for the treatment of NAS. Overall, there was a significant difference in LOS (p = 0.003) and LOT (p = 0.022) in days, morphine exposure (p = 0.024) in mg/kg, and Finnegan sleep scores (p = 0.015). There were no significant differences in clonidine exposure (p = 0.120) in mg/kg and Finnegan crying scores (p = 0.561).

LOS

One-way ANOVA revealed a significant difference in mean LOS in days, F (2, 77) = [6.398], (p = 0.003). Post-hoc comparisons indicated that the mean difference between LOS for Group 1 was significantly decreased from Group 3, (p = 0.006, 95% CI = [3.47, 24.59]). The mean difference between LOS for Group 2 was significantly decreased from Group 3 (p = 0.013, 95% CI = [2.52, 26.52]) (Table 1).

LOT

One-way ANOVA revealed a significant difference in LOT in days, F (2, 79) = [3.993], (p = 0.022). Post-hoc comparisons indicated that the mean difference between LOT for Group 1 was significantly decreased from Group 3 (p = 0.041, 95% CI = [0.40, 22.64]) (Table 1).

Morphine

The Kruskal-Wallis Test revealed a significant difference in morphine exposure in mg/kg across the three groups, H (2, n = 80) = [7.485], (p = .024). Group 3 recorded a significantly higher median morphine exposure in mg/kg (Median (Md) = 10.98) than Group 1 (Md = 5.22) and Group 2 (Md = 7.24). Post-hoc comparisons using a Bonferroni-adjusted alpha level revealed a significant difference and decrease in morphine exposure in mg/kg of Group 1 compared to Group 3 (p = .006) (Table 1).

Clonidine

One-way ANOVA revealed a non-significant difference in clonidine exposure in mg/kg, F (2, 77) = [2.177], (p = 0.120). Post-hoc comparisons indicated no significant differences in mean clonidine exposure in mg/kg (Table 1).

Crying

One-way ANOVA revealed a non-significant difference in mean Finnegan crying scores and Groups, F (2, 77) = [0.582], (p = 0.561). Post-hoc comparisons and results indicated no significant differences in mean Finnegan scores for crying and Groups (Table 1).

Sleeping

One-way ANOVA revealed a significant difference in mean sleeping in Finnegan scores, F (2, 77) = [4.412], (p = 0.015). Post-hoc comparisons indicated the mean difference between sleeping for Group 1 was significantly higher than Group 2 (p = 0.018, 95% CI = [0.0181, 0.2401]).

Nursing Survey Findings

Seventy-six total nurses (N = 76) completed the survey prior to initiation of the novel bassinet trial and 55 nurses (N = 55) completed the survey after the trial ended. A preamble of the digital survey enabled nurses to decline answering specific questions. Sample sizes varied among questions in the pre- and post-survey. Age of the nursing staff ranged from 21 to over 51 years of age and years of experience and time worked in the NICU ranged from less than one year to over 10 years, respectively. Pre-survey results showed 40.8% of nurses (n = 31) had over 10 years of experience working in the NICU and 46.1% (n = 35) had greater than 10 years of experience caring for infants with NAS. Pre-implementation, only 14.5% of nurses (n = 11 out of 74) had ever used a novel bassinet while post-survey revealed 100% (N = 55). When asked about the time per shift to console/sooth an infant with NAS, 50% of the nurses (n = 10 out of 20) reported 1–2 hours on the pre-survey and 33.3% of the nurses reported 2–3 hours (n = 15 out of 45) post-implementation. Interestingly, the percentage of nurses reporting 3–4 hours per shift also increased post-implementation from 5% (n = 1 out of 20) to 13.3% (n = 6 out of 45). Nurses were asked to use a 5-point Likert-scale to rank the helpfulness of certain resources for decreasing the nursing time spent consoling/soothing infants with NAS (1 = not helpful; 5 = most helpful). There was a 0.17 difference for vibrating seats/swings pre-survey (Mean = 4.43, Standard Deviation = 0.66, N = 75) compared to post-survey (M = 4.26, SD = 0.62, n = 54) as well as the use of volunteers and other ancillary staff pre-survey (M = 4.13, SD = 1.03, n = 72) to post-survey (M = 4.43, SD = 0.92, n = 54). The consensus based on a 5-point Likert-scale on the post-survey was the novel bassinet helped keep babies safely in the supine position (M = 4.13, SD = 0.89, n = 54) and it facilitated a safe sleep position (M = 4.24, SD = 0.85, n = 54). Qualitative data from open-ended questions revealed the time spent consoling infants with or without the novel bassinet was variable depending on the infant. Nurses reported a challenge in the care of infants with NAS was balancing time needed to console infants with other time-sensitive tasks. Post-survey results revealed 97.8% (n = 44 out of 45) of the nurses indicated they felt a helpful feature of the novel bassinet was its safety and ability to console. Common challenges and suggested changes reported by nurses pertained to novel bassinet positioning, speed, and function.

This study revealed implementation of a novel bassinet failed to enhance non-pharmacologic management of infants with NAS admitted to an open-bay NICU. The novel bassinet was significantly associated with an increased length of hospitalization and exposure to pharmacologic treatment of our NAS study population. These findings were contrary to our original hypothesis that the novel bassinet would decrease LOS and pharmacologic exposure. It was presumed the unique features of the novel bassinet would collectively act as an effective NPI for NAS, especially in an open-bay NICU. Its ability to adjust the intensity of rocking to the infant’s intensity of agitation was a characteristic presumed to benefit vestibular sensory stimulation that has increasingly been suggested to improve behavioral responses of infants with intrauterine drug exposure (15–19).

Prior examples of altering the proximal environment using various modified bassinet mattresses have shown benefits in the non-pharmacologic management of infants with opioid withdrawal. Oro and Dixon described benefits of implementing a commercially available non-oscillating waterbed for non-pharmacologic management of infants with NAS (20). Those infants placed on a waterbed mattress required significantly less pharmacologic treatment and had lower withdrawal scores and earlier consistent weight gain compared to controls. The authors attributed the findings as a favorable behavioral response to proximal tactile and vestibular stimuli input provided by the non-oscillating waterbed upon movement by the infant.

In a recent randomized study by Bloch-Salsbury et al., a vibrating crib mattress with a continuous three-hour on-off cycle of low stochastic vibrotactile stimulus (SVS) was compared to a standard bassinet mattress for treatment of newborns with prenatal opioid exposure (21). Infants were randomized to the SVS mattress or standard bassinet mattress in the newborn nursery where they remained until transferred to the NICU for pharmacologic treatment or discharged home. They found daily duration of SVS was associated with a 50% reduction in the need for morphine compared to controls. Also, infants who received SVS and required less than three weeks of morphine treatment had fewer treatment days and less cumulative morphine dose compared to controls. Sub-analysis of caretaker bedside logs found caretaker holding time reduced the need for morphine administration equivalent to SVS. The authors concluded greater exposure to tactile stimulation, whether SVS vibration of holding by caretakers, resulted in less need for pharmacologic treatment and that mechanosensory stimulation provided by direct human contact or SVS appeared to reduce NAS withdrawal symptoms.

Explaining why the commercially available horizontal rocking bassinet used in our study failed to enhance non-pharmacologic management of prenatally opioid exposed infants is a challenge. When comparing devices, they each employ different motion effects that could result in different tactile, proprioceptive, and vestibular inputs. Oro and Dixon used a non-oscillating waterbed that upon infant movement provided direct conforming tactile and vestibular input (20). Alternatively, the mattress used in the study by Bloch-Salsbury et al. provided a three-hour on-off cycle of low-intensity random vibrotactile stimulation (21). The commercially available novel bassinet used in this study provided a horizontal motion that intensified as an infant became more agitated. Based on our findings, it is possible subjecting NAS infants to a specific type, duration, and intensity of motion may result in adverse instead of beneficial tactile and vestibular sensory input and limit the management of these patients.

Interestingly, in 1999 Karen D’Apolito compared the use of a mechanical rocking bed to a standard bassinet for drug-affected infants (22). Infants randomized to the rocking bassinet had increased withdrawal symptoms, sleep deprivation, and suboptimal neurobehavioral function on day of life seven as defined by lower cluster scores on the Brazelton Neonatal Behavioral Assessment Scale (22). The authors suggested the ineffectiveness of the rocking bed possibly was related to excessive stimulation during the acute phase of infants experiencing withdrawal from prenatal opioid exposure (22). Similarly, excessive stimulation may hold true as an explanation for the ineffectiveness of the novel bassinet utilized in this study.

The novel bassinet used in our study is available commercially and traditionally targeted at healthy infants in the first six months of life to enhance sleep and decrease agitation. The novel bassinet has not been specifically studied or marketed as a device to assist in non-pharmacologic management of infants exposed to opioids in utero. It was our hypothesis that disorganized sleep and agitation characteristic of NAS may be similar to that of non-opioid exposed infants and these infants would potentially benefit from use of the novel bassinet. However, the novel bassinet in our study failed to have any significant effect on Finnegan crying or sleeping scores. How non-opioid exposed infants versus those with NAS process and respond to various tactile and vestibular stimuli is beyond the scope of this study but our results and those discussed suggest infants with NAS respond differently to position and specific type, duration, and intensity of motion.

Our Occupational Therapy (OT) colleagues were first to voice concerns regarding study participants placed in the novel bassinet. They were troubled by the length of time NAS infants assigned to the novel bassinet were swaddled and kept supine. Supine position is compliant with the 2022 American Academy of Pediatrics recommendation for safe sleep, but Maichuk et al., found infants exposed prenatally to opioids had improved sleep patterns, decreased activity, stabilization of respirations and heart rate, and lower NAS scores with prone positioning (11, 23). With an unknown contribution to outcome, periods of prone positioning did occur for infants managed in Group 1 (control group) and Group 2 (NPI), but not Group 3 (NPI + Novel Bassinet). Swaddling methods while using the novel bassinet were also of concern and restricted self-soothing behavior by inhibiting the ability of the infant to direct hands to their mouth. Lastly, it was questioned if the intensity and horizontal direction of motion would adversely affect vestibular input and development of self-soothing behaviors. As a result of our OTs’ concerns, an early review of our data occurred before completion of the goal number of novel bassinet patients and prompted us to discontinue the study.

The pre- and post-nursing survey of the novel bassinet for the management of NAS infants also indicated a neutral opinion regarding effectiveness. The majority of nurses that participated in the survey found ancillary staff and volunteers more helpful in decreasing nursing time spent soothing and consoling infants compared to the novel bassinet. Our survey results contrast with those recently published by Gellasch et al. regarding the same bassinet (24). Their survey indicated providers perceived the bassinet as supporting patient care, reducing provider stress, and saving caretakers an estimated 2.2 hours per shift. Their bassinet survey, however was not limited to prenatally opioid exposed infants but for differing clinical scenarios involving patients cared for in NICUs, pediatric intensive care units, and general hospital pediatric floors (24).

Limitations

There are significant limitations of our study. First, our patient sample size was less than desired with only 21 infants enrolled in Group 3 (NPI + novel bassinet) instead of the calculated sample size of 37 infants. This was in part a result of terminating the study early after a preliminary review of the data revealed an alarming increase in LOS, LOT, and morphine exposure in mg/kg for infants in Group 3. Additionally, infants were not randomized into study groups which may have increased biases regarding our results. A third limitation involved the nurse satisfaction survey regarding use of the novel horizontal rocking bassinet. We were unable to identify if pre- and post-test responses were from the same participants which may have also contributed to interpretation biases. We also do not have long term follow-up of our study population which would greatly validate our short-term outcomes and concerns.

The novel horizontal rocking bassinet used in this study was not effective as a NPI for infants pharmacologically treated for NAS in an open-bay NICU. Our unexpected outcomes verify the importance of providing evidence through research to support an intervention rather than assuming its effectiveness. Modifications may be indicated, and specific guidelines established if this device is to be implemented in the management of NAS patients. Further research that incorporates multidisciplinary perspectives is needed to assess responses to the novel bassinet and its impact on long-term outcome for NAS patients.

Author Contributions

RS and TR designed and conceptualized the study. AG, AG, and JS assisted with family/staff education and study implementation. JS, AG, AG, and TR assisted with patient enrollment. CG and JS played a major role in data acquisition. SB and R? assisted with data collection and calculations. AB with the major role in statistical analysis of the data and summarizing of the results. TR with role to draft preliminary manuscript with critical contributions to intellectual content and revisions by RS, AG, AG, JS, CG, AB, RP and TR. All authors approved the final manuscript as submitted and agree to the accountable for all aspects of the work.

Funding: None

Competing Interests

Bassinet Smart Sleepers were provided by Happiest Baby and results were reported to Happiest Baby. Happiest Baby also waived 5S course/certification fees ($195) for three NICU nurses.

Ethics approval and consent to participate:

IRB and organizational approval was obtained for this study – IRB # 21.0555.

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Yes there is potential conflict of interest.

Pharmacologic Treatment and Length of Hospitalization for Neonatal Abstinence Syndrome (NAS) in an Open Bay Neonatal Intensive Care Unit (NICU) Using Novel Non-Pharmacologic Interventions

Status:

Version 1

Abstract

Objective

Study Design:

Results

Conclusion

Introduction

Methods

Nursing Satisfaction Survey

Data Analysis

Results

LOS

LOT

Morphine

Clonidine

Crying

Sleeping

Nursing Survey Findings

Discussion

Limitations

Conclusions

Declarations

References

Additional Declarations

Status:

Version 1