A Roadmap to Improved Quality Outcomes in Neonates Exposed to Illegally Manufactured Fentanyl

Q: What problem does the study address in neonates exposed to illegally manufactured fentanyl?

The study targets rising NOWS incidence and the lack of a known optimal treatment approach for severe fentanyl withdrawal in infants.

Q: How did the team adapt care for NOWS before implementing the modified ESC model?

They used quality improvement in two phases, starting with a hybrid Finnegan/ESC protocol from May 2023 to address hospital barriers, then moving to full ESC management.

Q: What outcomes showed improvement, and were any safety concerns observed?

Across 217 infants, mean LOS decreased by 29% (hybrid) and 49% (ESC), with reductions in morphine days and doses; no significant apnea occurred and naloxone was not used.

Sep 29, 2026

Uploaded by Kyle

Neonatal opioid withdrawal syndrome (NOWS) incidence has risen, and illegally manufactured fentanyl may be a key contributor. Optimal treatment for severe fentanyl withdrawal in infants is unclear. A multidisciplinary quality-improvement project reduced mean length of stay (LOS) for infants with NOWS by 20% over 19 months using a fentanyl-adapted transitional phase before implementing a modified Eat, Sleep, Console (ESC) model. Results from 217 infants exceeded targets with mean LOS reductions of 29% (hybrid) and 49% (ESC), alongside fewer morphine days and doses, without significant apnea.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages10

Reading Time25 min

AccessFree to download

Objective

Study design

Results

Conclusions

Background: fentanyl exposure and NOWS

Treatment background: Finnegan versus ESC

Implementation barriers and care model details

ORIGINAL ARTICLES A Roadmap to Improved Quality Outcomes in Neonates Exposed to Illegally Manufactured Fentanyl Cristiane G. Lin, MD, PhD1 ,2 ,3 , Christine Wade, BSN, RN1 , Becky Micetic, BSN, RN1 , Pooja Rangan, MBBS, MPH2 ,3 , Natalie Wade, BS1 , and Vrinda Arora, MD1 ,2 ,3 Objective The incidence of neonatal opioid withdrawal syndrome (NOWS) has dramatically increased , and illegally manufactured fentanyl may be a significant contributor. The optimal treatment approach for an infant experiencing severe withdrawal from fentanyl is unknown. Our aim was to decrease the mean length of stay (LOS) by 20% over 19 months for infants with NOWS by implementing a transitional phase before establishing our modified Eat, Sleep, Console (ESC) model of care. Study design A multidisciplinary team used quality improvement methodology to improve treatment of NOWS in 2 phases, each adapted to fentanyl’s complex pharmacology. Beginning May 2023, a hybrid Finnegan/ESC protocol was implemented to address hospital barriers for a year before initiating full ESC management. Data were collected on infants >35 weeks of gestational age admitted to a level III neonatal intensive care unit. Primary metrics included LOS and total days/doses of morphine. Rates of apnea and naloxone were used as balancing measures. The LOS was plotted on a statistical process control chart and the data were summarized with descriptive statistics. Results Outcomes were analyzed for 217 infants. The aim was exceeded with a mean LOS reduction of 29%(hybrid) and 49%(ESC) . On average , decreased morphine days (22 .5, 11.2, 6.9, P < .001) and doses (162, 63, 14, P < .001) also were observed. No significant apnea occurred, nor was naloxone used. Conclusions This quality improvement project provides a successful fentanyl-adapted ESC model that may be adopted to decrease postnatal morphine usage and LOS. (J Pediatr: Clin Pract 2025;18:200190) . I n the current US opioid epidemic, overdose from illegally manufactured fentanyl (IMF) remains a predominant cause of death. Nationally, education and abatement efforts are ongoing.1-5 This increase in ultrapotent opioids like IMF has led to use during pregnancy, subsequently increasing neonatal abstinence syndrome (NAS) or specifically, neonatal opioid with- drawal syndrome (NOWS) .1,6,7 Consequently, the incidence of NAS in our state from 2009 to 2022 increased nearly 6-fold up, to 11. 1/1000 infants hospitalized.8 In response, the state’s Department of Health developed a NAS Action Plan providing resources for pregnant persons with opioid use disorder (OUD) as well as leading our hospital system to prioritize implementation of the Eat, Sleep, Console (ESC) model of care.9, 10 Fentanyl, and its analogs, are synthetic, high-binding full agonists ofthe mu opioid receptor. They are highly lipophilic and quickly cross the blood-brain barrier, resulting in rapid onset of action. Moreover, they are ultrapotent (100 to 10 000-fold more than morphine), have high abuse potential, and more severe withdrawal symptoms.11-18 Because of the severity of fentanyl withdrawal, modifications to adult medication protocols for OUD were necessary. To achieve improvement in symptoms, the doses of methadone or buprenorphine required rapid escalation and higher maintenance doses.12, 13, 19-22 Similar to adults, neonates exposed to in utero fentanyl display severe withdrawal symptoms. Traditional treatment regimens may not successfully capture these infants’NOWS symptoms, and per recent literature review, there are no published fentanyladapted protocols.18,23 Historically, the Modified Finnegan Neonatal Abstinence Scoring System (MFNASS) relied on scheduled opioid administration, with slow dose escalation until capture, followed by gradual weaning, which often prolonged medication exposure and hospitalization.24-28 The American Academy of Pediatrics now accepts the function-based ESC method, first described by Grossman et al,9 as an a

FAQs

What problem does the study address in neonates exposed to illegally manufactured fentanyl?

The study targets rising NOWS incidence and the lack of a known optimal treatment approach for severe fentanyl withdrawal in infants.

How did the team adapt care for NOWS before implementing the modified ESC model?

They used quality improvement in two phases, starting with a hybrid Finnegan/ESC protocol from May 2023 to address hospital barriers, then moving to full ESC management.

What outcomes showed improvement, and were any safety concerns observed?

Across 217 infants, mean LOS decreased by 29% (hybrid) and 49% (ESC), with reductions in morphine days and doses; no significant apnea occurred and naloxone was not used.

Sep 29, 2026

Uploaded by Kyle