The Effect of Aromatherapy on Neonatal Abstinence Syndrome and Salivary Cortisol Levels

The United States, Appalachia, Eastern Kentucky in particular, is in the midst of a major
opioid abuse epidemic. This current epidemic is driven by misuse of prescription painkillers,
i.e. Subutex and Saboxone. As prescription pills become more expensive and harder to acquire,
addicts are seeking similar, cheaper drugs; such as heroin. From 1998 to 2011, the prevalence
of opioid abuse and dependence amongst pregnant women has increased by 127%, from 1.7 per
1000 to 3.9 per 1000. Neonatal Abstinence Syndrome (NAS) or neonatal opioid withdrawal
syndrome is a condition produces gastrointestinal and autonomic neurologic dysfunction.
Infants with severe withdrawal experience dysregulation of autonomic functions, resulting in
feeding difficulty, diarrhea, excessive sleepiness, and tremors.Nearly two thirds of all
babies exposed to opioids during gestation will require admission to a neonatal intensive
care unit for management of withdrawal symptoms. During a typical year the Neonatal Intensive
Care Unit (NICU) at Kentucky Children's Hospital admits approximately 100-120 infants
exhibiting NAS symptoms; these infants have a typical length of stay of 24 days if they
require pharmacologic treatment.

The mainstay of treatment for NAS involves opioid replacement therapy with morphine to
minimize withdrawal symptoms. Once symptoms are well controlled, the infant is said to have
been "captured." At this point a slow weaning of his morphine dose occurs. The infants'
clinical status is assessed with the Finnegan Scoring system, which examines symptoms such as
crying, excessive sleepiness or difficulty sleeping, insomnia, or tremors along with
objective findings such as temperature and respiratory rate.

In addition to pharmacotherapy, alternative and complementary medicine techniques are slowly
entering the NAS treatment algorithm. Treatments such as music therapy infant massage,
kangaroo care, aromatherapy, and acupressure are now employed in NICUs in addition to
traditional opioids replacement. However, few studies exist in the literature to evaluate
their effectiveness.

Aromatherapy is the practice of using natural essential oils to achieve a desired effect in
an individual. Scents such as lavender and chamomile have been documented to have a soothing
calming effect. Studies involving infants shown that lavender not only reduce crying and
enhance sleep, but also reduce levels of salivary cortisol, a stress hormone. Additionally,
aromatherapy is currently used as an adjunctive therapy at the University of Kentucky's
Markey Cancer Center.

Salivary cortisol is a non-invasive biomarker that has proven useful for monitoring stress in
neonates. It is a simple and painless method for monitoring the stress hormone cortisol.
Salivary cortisol has been used successfully in infants as a method to assess infant stress
associated with prone position versus supine positioning.These studies have shown that
salivary cortisol levels vary with stressful or soothing stimuli.

To date, no dangerous or deleterious effects have been described from traditional
inhalational use of aromatherapy or with salivary cortisol sampling. Studies have shown
aromatherapy to be an effective adjunctive therapy by proving a calming effect. In our
patient population it may prove to be a useful complimentary therapy ultimately reducing
infant stress, hospital length of stay, and burden of opioid use. Additionally, salivary
cortisol's ease of collection and non-invasive nature make it an ideal biomarker to study.

Inclusion Criteria:

- Infants greater than or equal to 36 weeks EGA

- Intrauterine opioid exposure

- Primary diagnosis of NAS

- Parental permission to participate

Exclusion Criteria:

- Infants less than 36 weeks EGA

- Major congenital anomalies

- Latrogenic drug withdrawal

- Diagnosis of infection or respiratory distress

- Prior initiation of opioid replacement therapy

- Non-English speaking

- Infants with respiratory conditions