Objective: To reduce the number of neonatal abstinence syndrome incidents by 5%  per year for future years.

What is Neonatal Abstinence Syndrome?: Neonatal Abstinence Syndrome (NAS) is a drug withdrawal syndrome that opioid-exposed neonates experience shortly after birth.  NAS is characterized by behavioral dysregulation that occurs within 2-3 days of birth for infants exposed chronically to opioids in-utero. Signs and symptoms include altered sleep, high muscle tone, tremors, irritability, poor feeding, vomiting and diarrhea, sweating, tachypnea, fevers and other autonomic nervous system disturbances. All opioids can cause withdrawal symptoms, including methadone and buprenorphine which are used for opioid treatment, as well as short acting agents such as oxycodone, heroin and fentanyl. In Connecticut, increasing prevalence of opioid use in pregnancy has led to significant increase in NAS over the past decade.

Graph: The above graph represents the number of hospital discharges for newborns in Connecticut, born with NAS due to intrauterine exposure to opioid drugs. The data represented in the graph are for years 2003 to 2017 which shows substantial increase in numbers during this time frame. In year 2003 the NAS related hospital discharges were at 137 and the number gradually increased to 447 in year 2015.  The number has remained steady between 2015 and 2017.  The percent difference in increase of NAS between years 2003 to 2017 is 161.3%. In future years, we would like to achieve at least a 5% reduction in NAS incidents each year, when compared to the previous year.

Data Source:   CHIME hospital discharge data is used as the primary source. ICD 9 (prior to October 1, 2015) and ICD 10  (after October 1, 2015) codes for NAS are used for primary diagnosis and primary cause of injury unless otherwise noted. An individual newborn can have more than one hospital visit and numbers are based on number of hospital discharges and not the number of individuals.

Data updated: 11-06-2018

State of Connecticut Department of Public Health collaborates with state/local stakeholders and partners to address Neonatal Abstinence Syndrome (NAS) across systems.  Some of these include:

1) Connecticut’s Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is funded by the U.S. Department of Agriculture. Nationwide, over half of all infants are served by WIC, which provides supplemental foods, health care referrals, nutrition education and breastfeeding promotion. Also provides support to low-income pregnant, breastfeeding and non-breastfeeding postpartum women, and infants and children up to age five years of age who are found to be at nutritional risk. https://portal.ct.gov/DPH/WIC/WIC

2) Connecticut Perinatal Quality Collaborative (CPQC) promotes high quality maternal and newborn care across the continuum of acuity, from community hospital to neonatal intensive care environment by: facilitating cooperation among hospitals and health care providers; supporting evidence-based newborn care practices; sharing educational and training resources; gathering data that informs members and other stakeholders. CPQC is administered through Connecticut Hospital Association's education affiliate and sponsored by Connecticut Healthcare Research and Education Foundation (CHREF). https://www.cpqc-ct.com/

3) Neonatal Abstinence Syndrome: Comprehensive Education and Needs Training (NASCENT) Project: In 2016, Connecticut Hospital Association (CHA) affiliate, the Connecticut Healthcare Research and Education Foundation (CHREF), initiated the Neonatal Abstinence Syndrome: Comprehensive Education and Needs Training (NASCENT) project as a statewide collaborative to reduce opioid use disorder in women of childbearing age and, ultimately, the incidence of NAS in babies.  NASCENT provides online and in-person education about multimodal analgesia and opioid prescribing to clinical providers, nurses, and office staff, and strives to decrease rates of NAS by reducing the number of individuals exposed to opioids in the first place.  https://healthymomsandbabiesct.org/clinicians/initiatives

4) Connecticut’s Substance Exposed Infants-Fetal Alcohol Syndrome Disorder (SEI-FASD) Collaborative is aimed at creating a broader understanding of the impact of prenatal substance use on infants and their families.Through a DCF and DMHAS co-funded initiative, the SEI-FASD workgroup seeks to improve capacity for diagnosis, treatment and prevention of prenatal substance exposure through education, establishing policies and increasing coordination of services that engage and support families impacted by substance abuse. 

5) Connecticut’s MCH Coalition consists of 120 individuals representing state agencies, providers, funders, and advocates working in concert with the state’s maternal and child health population. This Coalition serves as the Maternal, Infant, and Child Health (MICH) Action Team for the Department of Public Health’s State Health Improvement Plan (SHIP).

 6) Every Woman Connecticut (EWCT) is a collaborative initiative established, in partnership with consumers, health care providers, state agencies, professional organizations, and community-based partners, to improve women’s pre/inter-conception health status and reduce adverse birth outcomes, including preterm and low birth weight, with a focus on achieving health equity. www.everywomanct.org 

7) The Connecticut Alcohol and Drug Policy Council (ADPC) is a legislatively mandated body comprised of representatives from all three branches of State government, consumer and advocacy groups, private service providers, individuals in recovery from addictions, and other stakeholders in a coordinated statewide response to alcohol, tobacco and other drug (ATOD) use and abuse in Connecticut. https://www.ct.gov/dmhas/cwp/view.asp?q=334676

8) The Women’s Services Practice Improvement Collaborative (WSPIC) is designed to enhance its behavioral health service system for women by improving the quality of services for women receiving substance use treatment in Connecticut, and thus positively impact treatment outcomes statewide. https://www.ct.gov/dmhas/cwp/view.asp?q=393160

Understanding prenatal substance exposure and its effects and educating communities about teratogenic effects of drugs during pregnancy will help reduce NAS incidents in the State of Connecticut. Partnering with professional organizations, multiple state agencies and public/private professional organizations to educate target populations will lead to achieving the goal. The target population to educate about NAS should include: young women, community at large, medical providers, social services and treatment providers, schools, higher education programs, child welfare staff and foster/adoptive parents. A universal protocol needs to be developed and executed, defining procedures for screening for maternal substance misuse and substance disorder in order to implement comprehensive treatment for infants at risk or showing withdrawal symptoms.

CT Hospital Association (CHA) is in the beginning phases of another NAS initiative focused on a patient-centered approach to caring for mothers and new babies with NAS.  Called Eat, Sleep, Console (ESC). This program is based on research conducted at Yale New Haven Hospital (YNHH) that led to decreased use of medication, decreased length of stay, and emotional benefits for both mother and baby, as well as lower healthcare costs. This initiative began with an assessment of YNHH's current protocol around care of infants with NAS.  Members of the CHA sponsored CPQC  (Connecticut Perinatal Quality Collaborative) are being encouraged to pursue PDSA  (Plan, Do, Study Act) Quality Improvement projects to assess the effectiveness of ESC in their hospitals.

1. DPH will strengthen collaboration with Neonatal Abstinence Syndrome (NAS) partners by participating in statewide NAS collaborative like Connecticut Perinatal Quality Collaborative; analyzing hospital discharge datasets to identify number of infants with NAS; sharing such information with partners proactively.
2. DPH will be adding Fetal Alcohol Syndrome (FAS) back into ICD10 coding within the Congenital Malformations, Deformations and Chromosomal Abnormalities in the Birth Defects Registry. This will occur in early 2019.
3. DPH will strengthen bio surveillance by conducting ongoing surveillance of the opioid crisis statewide, including multiple partnerships with other state agencies supporting women and infants, with a focus on Neonatal Abstinence Syndrome.
4. DPH will add substance use and withdrawal symptom fields to the CT Newborn Screening System and trigger new set of questions when NAS is present.
5. DPH will improve near real-time surveillance of the incidence of NAS statewide in order to inform prevention, treatment, and recovery services and resources across the state.
6. DPH is planning to implement the opioid supplement in the Pregnancy Risk Assessment Monitoring (PRAMS) Questionnaire starting in April 2019.