Optimal Care for NAS: Are We Moving in the Wrong Direction?

The growing numbers of infants born to women with opioid use disorder (OUD) and experiencing neonatal abstinence syndrome (NAS), and the increasing costs of their care,1 has led to a reassessment of prevailing approaches to clinical treatment. Emerging protocols that reduce assessment to limited domains of infant functioning are being adopted and advanced, raising several concerns. NAS is a “generalized multisystem disorder”2 causing a dysregulation of the central and autonomic nervous systems that manifests in a variety of physiologic and neurobehavioral signs, unique to each infant, in the domains of sleep-awake control, motor and/or muscle tone, autonomic functioning, and sensory processing and/or modulation.3 Conventional NAS care incorporates nonpharmacologic treatment (ie, the assessment of the variable dysregulation in specific domains of infant functioning particular to each infant, assessment of maternal capacities to understand and address them, and alterations to the environment and handling to minimize dysregulation with maternal support and education)3 as the principal, first-line therapy for any substance-exposed infant.4 Pharmacotherapy is indicated for infants displaying persistently impaired functioning despite maximal, individualized nonpharmacologic treatment. NAS scoring tools, such as the Finnegan tool5 and variants traditionally used to guide the introduction and weaning of pharmacotherapy, have weaknesses such as subjective scoring and scoring of items that can be attributed to typical newborn behaviors or other conditions, potentially leading to overtreatment and lengthy hospitalizations. A new approach, the Eat, Sleep, Console (ESC) assessment tool, combined simultaneously with other interventions, including the “nonpharmacologic care bundle(s),” attention to maternal needs, and alterations in pharmacotherapy, is being recently promoted. The ESC approach forgoes the identification and/or description of NAS-associated signs and symptoms …