Phenobarbital for NOWS: Less Morphine, Briefer Hospital Stay

(Reuters Health) – Infants with neonatal opioid withdrawal syndrome (NOWS) may have shorter hospital stays and spend less time on morphine when they receive phenobarbital as secondary therapy, a U.S. study suggests.

Researchers examined data on 563 infants with NOWS who were treated with morphine at one of 30 hospitals in the U.S. to see how secondary therapy with phenobarbital or clonidine might impact length of hospital stay, duration of opioid treatment, or peak morphine dose. Overall, 180 patients in the study (32%) received secondary therapy with either phenobarbital (n=72) or clonidine (n=108).

Infants who received phenobarbital had a mean length of stay 10 days shorter and mean duration of morphine treatment 7.5 days shorter than babies who received clonidine as secondary therapy, researchers report in Pediatrics.

There was no difference in peak morphine dose based on which medicine was used for secondary therapy.

However, infants who took phenobarbital were more likely to be discharged from the hospital still on opioid treatment than babies who took clonidine (78% vs 29%).

“Phenobarbital has been used for many years in neonatology for neonatal seizures and withdrawal, and pediatricians are comfortable sending babies home while still receiving phenobarbital and having them wean off the medication at home,” said lead study author Dr. Stephanie Merhar, an associate professor of pediatrics at Cincinnati Children’s Hospital in Ohio.

There are more safety concerns with the weaning of clonidine, including the potential for rebound hypertension, so pediatricians are less comfortable sending babies home while they are still receiving clonidine, Dr. Merhar said by email.

“Whether or not this is the best way to provide care or not is a source of debate,” Dr. Merhar said.

One limitation of the study is that researchers lacked data on any sociodemographic barriers to discharge that might have impacted length of stay independent of treatment approaches, the study team notes. It’s also possible that practice differences may have influenced the results, particularly because many patients came from larger medical centers rather than small community hospitals.

Even so, the results underscore that clinicians who care for newborns need to be familiar with NOWS and the evolving management approaches, said Dr. Jane Brumbaugh, a neonatologist at Mayo Clinic Children’s Center in Rochester, Minnesota, who wasn’t involved in the study.

“Increasingly, the first line therapy for NOWS is non-pharmacologic treatment that empowers the newborn’s parent or caretaker, and then the second line therapy commonly is an opioid medication,” Dr. Brumbaugh said by email.

For the subset of newborns who have clinically significant withdrawal despite the use of non-pharmacologic tools and an opioid medication, a third line therapy may be indicated, which might include phenobarbital or clonidine, Dr. Brumbaugh said.

“The current study advances science by identifying the potential risks and benefits associated with phenobarbital and clonidine as adjunctive therapies,” Dr. Brumbaugh said. “The application of this study may vary by institution and by community based on the resources available to support newborns and families affected by NOWS.”

SOURCE: Pediatrics, online February 25, 2021.

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