TOP 7 - Evaluation of the Withdrawal Assessment Tool – Alpha 2 Agonist for Iatrogenic Withdrawal Syndrome in Infants

Publication Number: 3801.TOP 7

Randy Moore, Nationwide Children's Hospital, Columbus, OH, United States; Jonathan L. Slaughter, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, United States; Zachary Farmer, Nationwide Children's Hospital, Coluimbus, OH, United States; Sara Conroy, Nationwide Children's Hospital, Columbus, OH, United States

Background: In the past two decades, alpha-2 agonists have increasingly been used in the infant population for sedation. There is currently no validated measurement tool to evaluate Iatrogenic Withdrawal Syndrome (IWS) from alpha-2-agonists in infants, which may occur in infants receiving 5 or more consecutive days of therapy. The PANDEM guidelines for infants and children state that until a validated screening tool is developed, adjunct use of a benzodiazepine or opioid screening tool, in addition to professional monitoring, may be used to monitor for alpha-2 agonist IWS. Many centers use the Withdrawal Assessment Tool-1 (WAT-1) for evaluation of iatrogenic withdrawal of alpha-2 agonists, as it is the most appropriate proxy. However, WAT-1 is only validated for opiate and benzodiazepine IWS. This reflects the need for a validated assessment tool to evaluate for alpha-2 agonist IWS.
A novel Withdrawal Assessment Tool - Alpha 2 Agonist (WAT-A2A) has been proposed as a potentially superior assessment tool for alpha-2 agonist withdrawal for children. Initial development and preliminary testing of WAT-A2A was performed by Solodiuk et al, 2024.

Objective: 1) Evaluate if infants, compared to the general pediatric population, present with similar clinical characteristics of IWS from alpha-2 agonists.
2) Assess agreement between WAT-A2A and WAT-1, in assessing alpha-2 agonist withdrawal.
This will facilitate further investigation comparing WAT-A2A to the gold standard, which is professional assessment by a skilled provider.

Design/Methods: This is a single-center retrospective cohort study using medical record data from 01/01/2021 through 07/01/2025 at Nationwide Children's Hospital NICU. Inclusion criteria are infants 0-12 months with 5 consecutive days of alpha-2 agonist therapy who were weaned off alpha-2 agonists. Exclusion criteria are nonviable infants. Data includes demographic information, WAT-1 scores, vital signs, and documentation pertaining to drug withdrawal. Post-hoc WAT-A2A scores will be calculated from already present data. Baseline demographics will be summarized using medians for continuous variables and counts for categorical variables. A scatter plot and Spearman rank correlation will estimate the association of the scores. The number of infants identified as going through withdrawal based on A2A dose adjustments and WAT-1 will be compared to those identified by WAT-A2A. Inter-score reliability will be determined by percent agreement and Fleiss' Kappa. Results of data analysis are anticipated in January 2026 with ongoing development of the abstract in February and March 2026.

Figure 1: Withdrawal Assessment Tool - Alpha-2 Agonist (WAT-A2A)
Components included in WAT-A2A that will be calculated based on existing retrospective data.

Figure 2: Withdrawal Assessment Tool-1 (WAT-1)
Components included in WAT-1, the most appropriate proxy used for evaluation of IWS from alpha-2 agonists in infants. Post-hoc WAT-A2A score is able to be calculated from existing WAT-1 data and concurrent vital signs.