121 - Small Steps, Big Gains: Improving Growth in Infants with Neonatal Abstinence Syndrome

Publication Number: 3115.121

McKenna Straus, Johns Hopkins All Children's Hospital, St Petersburg, FL, United States; Candice Guevara, Johns Hopkins All Children's Hospital, St Petersburg, FL, United States; Michelle Gilbert, Johns Hopkins All Children's Hospital, St Petersburg, FL, United States; Fauzia M. Shakeel, Johns Hopkins All Children's Hospital, St. Petersburg, FL, United States; Aaron M. Germain, Johns Hopkins All Children's Hospital, St Petersburg, FL, United States

Background: Postnatal growth insufficiency in infants with opioid-induced neonatal abstinence syndrome (NAS) is common secondary to withdrawal resulting in hypermetabolism, feeding difficulties, poor gastrointestinal absorption, and insensible water losses. Poor growth is associated with adverse neurodevelopmental outcomes and increased morbidity and mortality. There is variability in the approach to nutritional management of this cohort. Recent studies have shown early implementation of caloric fortification improves outcomes: improved growth, decreased failure of pharmacologic treatment and reduced length of stay. Local data from 2023-2024 revealed that 51% of infants with NAS had a loss of ≥1 weight z-score from birth to discharge and 39% had a maximum weight loss of ≥10% from birth weight.

Objective: To reduce the percentage of infants ≥35 weeks gestational age admitted to our NICU at ≤72 hours of life with a diagnosis of opioid-induced NAS that were discharged with a decrease in weight z-score ≥1 compared to birth from 51% to 30% by Sept 2025.

Design/Methods: Our initiative took place in a level 4 NICU within a freestanding children's hospital. Most infants were initially managed with the Eat, Sleep, Console method in the newborn nursery. Exclusion criteria included infants with significant comorbidities or discharged by 5 days of life. Outcome measures also included the percentage of infants with a maximum weight loss of ≥10% from birth weight. Process measures included adherence to protocols implemented. Balancing measures included length of stay and length of daily team rounds. Four PDSA cycles were completed between Nov 2024-Sept 2025: implementation of a standardized fortification protocol, education of the protocol to providers, standardization of speech language pathology (SLP) consultation, and consistent medical record documentation.

Results: The interventional cohort included 26 infants. Compared to baseline (n=45), the percentage of infants with NAS with a decrease of ≥1 weight z-score from birth to discharge decreased from 51% to 17%, exceeding our goal. The percentage of infants with a maximum weight loss of ≥10% from birth decreased from 39% to 14%. There was no significant difference in length of stay or length of daily team rounds. We aim to sustain these results with the inclusion of this protocolized approach into our NAS clinical practice guideline utilized by all providers and through periodic education.

Conclusion(s): Implementation of a standardized approach to early caloric fortification and SLP consultation significantly improved the growth amongst infants with NAS in our NICU.

Percentage of infants with loss of ≥1 weight z -score from birth to discharge
Control chart of primary objective. The mean percentage of infants with loss of ≥ 1 weight z-score from birth to discharge improved from 51% to 17% following PDSA cycles.​

Percentage of infants with max weight loss ≥10% from birth weight
Control chart of the percentage of infants with a maximum weight loss of ≥ 10% from birth weight. The mean improved from 39% to 14%. ​

Fortification protocol adherence
Run chart depicting the adherence to the fortification protocol. Adherence improved from 62% to 100% with continued education. ​