Leading Change Across the Region for Infants with Perinatal Opioid Exposure

How can we shift the standard of care to achieve better outcomes for babies born with perinatal opioid exposure?

A group of Children’s Hospital Colorado experts are shifting the standard of care for newborns with perinatal opioid exposure in Colorado and the surrounding states. When the state reported an alarming trend of increased cases of neonatal abstinence syndrome back in 2016, Susan Hwang, MD, PhD, and her colleagues knew they needed to shift to family-centered, trauma-informed care. That’s when the Colorado Hospital Substance Exposed Newborns (CHoSEN) Collaborative was born.

“We are partnering with families affected by substance use on this journey,” neonatologist Erica Wymore, MD, says. “The past has been marred with punishing people, criminal investigations and separating families, which has not proven to be effective. Changing the culture to help parents in this journey and support them toward recovery is critical.”

Prenatal exposure to alcohol or drugs can lead to poor birth outcomes such as preterm delivery, low birth weight, drug withdrawal and long-term cognitive and developmental delays. Traditionally, clinical teams would use a scoring tool to assess signs of opioid withdrawal that left room for a lot of variability in scoring, leading to longer lengths of stay.

In 2017, a study from Yale University changed that scoring criteria to focus more on a method called “eat, sleep, console” or ESC. This brought forward big questions: Can the baby eat when they are supposed to? Can they sleep for an hour undisturbed? Can they be consoled in an age-appropriate amount of time?

The CHoSEN Collaborative team wanted to reevaluate these standard of care guidelines for Colorado, in addition to partnering with other hospitals to improve care in multiple domains. The team focused on the following areas:

• Nonpharmacologic care: Previously, the standard of care was using opiate therapy for withdrawal symptoms. Now, the main focus is nonpharmacologic care and assessing effectiveness by implementing the ESC scoring tool. Foundations of this model include cue-based care, minimizing extra stimulation such as noise and light, promoting safe breastfeeding, encouraging parents to room-in or using volunteer cuddles to comfort infants.
• Increasing human milk: Local experts on breastfeeding and maternal substance use developed guidelines with eligibility criteria for the safe use of a mother’s own milk whenever possible.
• Promoting Eat, Sleep, Console: A CHoSEN Collaborative steering member was designated as the ESC expert in the state, offering in-person and virtual training sessions to teach hospital workers how to implement ESC, additionally working with Epic headquarters engineers for medical record documentation.
• Supporting families: Parental engagement was a big focus for the team. Research shows that increased parental presence during birth hospitalization and breastfeeding is associated with decreased lengths of stay and less need for opiate therapy. The team reports that teaching parents how to best console their newborn, increasing skin-to-skin time and encouraging rooming-in are key factors.
• Community collaboration: The CHoSEN Collaborative hosts biannual forums to connect and ensure the most current trauma-informed care standards are in practice. The Collaborative is a subcommittee of the Colorado Substance Abuse Trend and Response Task Force, which was created in a Colorado statute and is chaired by the state’s attorney general and supported by the Colorado Perinatal Care Quality Collaborative. The team has a collection of resources for professionals looking to implement some of these practices.

Now, there are 31 participating hospitals in the collaborative that share data, informational resources and participate in CHoSEN’s quality improvement program to assess their progress. The team measured the implementation of these methods and found that they resulted in shorter lengths of stay, from an average of almost 15 days to an average of fewer than six days. Additionally, the need for pharmacologic therapy dropped from 61% to just 23%, and among those who did require pharmacologic therapy, the length of stay was still reduced. Additionally, the collaborative’s experience has national recognition, with a special issue of NeoReviews highlighting their expertise.

Dr. Wymore believes focusing on this key time in a family’s life can make a big impact. She says, “Delivery is really the intersection of healthcare and parenthood, where we have this opportunity to intervene and support families."