Neonatal Abstinence Syndrome (NAS) Project

Neonatal Abstinence Syndrome (NAS) is a drug withdrawal syndrome that may occur in opioid-exposed newborns shortly after birth (1).  Symptoms typically occur 48-72 hours after birth and may include seizures, tremors, poor feeding, gastrointestinal distress, and high-pitched crying. In 2015, Patrick and colleagues reported that one baby who will suffer the effects of NAS is born every 25 minutes (2). The NAS epidemic is steadily increasing, overwhelming social service systems and public payers. Treating newborns impacted by NAS was associated with nearly $100 million in healthcare expenses and almost 25,000 days in Ohio hospitals in 2013, according to data from the Ohio Hospital Association. Prior to 2011, OPQC estimates up to 50% of neonates with NAS in Ohio were not receiving optimal care, despite evidence-informed data for identification and treatment of these infants. Thus, there is substantial opportunity for improvement. 

The OPQC NAS initiative was begun to reduce variation in identification and treatment and to optimize the care of infants with NAS. Building upon the progress of a pilot study at 6 centers of the Ohio Children’s Hospital Association (OCHA), the aim of the OPQC NAS Project was to increase the identification of and compassionate withdrawal treatment for full-term infants born with NAS, thereby reducing the length of stay (LOS) for these infants.  The project works with 54 sites including 26 Level 3 NICUs, 26 Level 2 Special Care Nurseries and 2 Level 1 Newborn Nurseries.

Phase 1 (January 2014 – June 2015)

In the first phase of the NAS Project, 52 OPQC site teams participated in adapting the Ohio Children’s Hospital Association (OCHA) care bundles, emphasizing compassionate care of infants and mothers, and standardizing both identification of affected infants and use of non-pharmacologic and pharmacologic care practices.

Phase 2:  Orchestrated Testing (October 2015 – December 2016)

Although hospitals standardized care in Phase 1, some variation in accepted practices remained across the collaborative, particularly in the components of the non-pharmacologic bundle. Project sites used Orchestrated Testing (OT) to learn from the accepted variation in practices across centers to identify the specific combination of factors (or practices) that yielded the greatest improvements in outcome. Sites self-selected into groups defined by the site’s practice related to formula type used in non-breastfed infants, while breast milk and breast feeding were encouraged for appropriate infants in all groups. Results suggest that use of 22 kcal/oz feeds could be beneficial in non-breastfed babies with NAS (3).  To confirm these findings, OPQC encouraged participating sites to adopt 22 kcal/oz formula as part of the nonpharmacologic care bundle and will monitor improvement in LOS over time.

Phase 3:  Sustain (January 2017 – June 2018)

Results from orchestrated testing are being used to improve OPQC’s standardized care protocols. The original recommended protocol from the Ohio Children’s Hospital Association pilot project has been updated to reflect OPQC’s findings and clinical evidence.  OPQC faculty believe that greater improvements in outcomes can be achieved across the state as more Ohio NICUs incorporate the improved standardized care protocols.  During the Sustain Phase, the 54 participating sites will continue to collect data and participate in collaborative learning opportunities.


Action & Sustain Period Calls

NAS Information (One-Pager)

NAS Key Driver Diagram

NAS Resource Materials for Providers

OPQC NAS Protocol


(1) Hudak ML, Tan RC, Committee on Drugs, et al. Pediatrics. 2012;129;e540-60

(2) Patrick SW, Davis MM, Lehmann CU, Cooper WO. Increasing evidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012. J Perinatol. 2015;35(8):650-655.

(3) Kaplan H., et al. Quality Improvement with Orchestrated Testing to Identify Best Formula Feeding for Neonatal Abstinence Syndrome (NAS).  Poster session presented at: Pediatric Academic Societies 2017 Meeting; 2017 May 6-9; San Francisco, CA.


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