501
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Kumar P, Biswas A, Iyengar H, Kumar P. Information gaps in newborn care and their potential for harm. Jt Comm J Qual Patient Saf 2015; 41:228-33. [PMID: 25977250 DOI: 10.1016/s1553-7250(15)41030-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Access to complete and correct patient information is vital for physicians to make appropriate patient care decisions and to avoid medical errors. However, the perinatal period represents a unique situation in which care of the fetus is initiated by an obstetrician and then assumed by either a pediatrician or a family practice physician after birth. This often abrupt handoff of care has the potential to result in an inadequate transfer of information and significant gaps in care. A study was conducted to determine the presence and extent of information gaps in newborn care. METHODS Maternal demographics and history, and results of all prenatal laboratory tests, were obtained from maternal interviews and medical records. The collected data were compared with information in infant medical records. A positive maternal history not documented in the infant medical record was counted as an information gap. RESULTS Of 72 enrolled mother-infant dyads, nearly all (71 [99%]) of mothers had at least one positive history in the areas reviewed, and 59 (82%) newborn charts had one or more information gaps. Thirty-eight (53%) newborn charts had one of two or fewer information gaps, and 17 (24%) had four or more information gaps. None of the infants with a maternal history of depression, positive family history of an infectious disease, potentially inheritable genetic disorder, or family history of phototherapy or exchange transfusion had these documented in their medical records. CONCLUSIONS The results of this study suggest that significant information gaps are common in newborn care at birth and may have the potential for an adverse impact on the care and outcomes of the newborn. Obtaining a history directly from the parents rather than relying on maternal medical records may minimize or eliminate these information gaps and thus improve newborn care.
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Affiliation(s)
- Prerna Kumar
- Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado, USA
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502
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Carbajal R, Eriksson M, Courtois E, Boyle E, Avila-Alvarez A, Andersen RD, Sarafidis K, Polkki T, Matos C, Lago P, Papadouri T, Montalto SA, Ilmoja ML, Simons S, Tameliene R, van Overmeire B, Berger A, Dobrzanska A, Schroth M, Bergqvist L, Lagercrantz H, Anand KJS. Sedation and analgesia practices in neonatal intensive care units (EUROPAIN): results from a prospective cohort study. THE LANCET RESPIRATORY MEDICINE 2015; 3:796-812. [DOI: 10.1016/s2213-2600(15)00331-8] [Citation(s) in RCA: 116] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 08/13/2015] [Accepted: 08/13/2015] [Indexed: 12/28/2022]
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503
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Wachman EM, Hayes MJ, Sherva R, Brown MS, Davis JM, Farrer LA, Nielsen DA. Variations in opioid receptor genes in neonatal abstinence syndrome. Drug Alcohol Depend 2015; 155:253-9. [PMID: 26233486 PMCID: PMC4581974 DOI: 10.1016/j.drugalcdep.2015.07.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 07/01/2015] [Accepted: 07/01/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND There is significant variability in the severity of neonatal abstinence syndrome (NAS) due to in-utero opioid exposure. We wanted to determine if single nucleotide polymorphisms (SNPs) in key candidate genes contribute to this variability. METHODS Full-term opioid-exposed newborns and their mothers (n=86 pairs) were studied. DNA was genotyped for 80 SNPs from 14 genes utilizing a custom designed microarray. The association of each SNP with NAS outcomes was evaluated. RESULTS SNPs in two opioid receptor genes in the infants were associated with worse NAS severity: (1) The PNOC rs732636 A allele (OR=3.8, p=0.004) for treatment with 2 medications and a longer hospital stay (LOS) of 5.8 days (p=0.01), and (2) The OPRK1 rs702764 C allele (OR=4.1, p=0.003) for treatment with 2 medications. The OPRM1 rs1799971 G allele (β=-6.9 days, p=0.02) and COMT rs740603 A allele (β=-5.3 days, p=0.01) were associated with shorter LOS. The OPRD1 rs204076 A allele in the mothers was associated with a longer LOS by 6.6 days (p=0.008). Results were significant point-wise but did not meet the experiment-wide significance level. CONCLUSIONS These findings suggest that SNPs in opioid receptor and the PNOC genes are associated with NAS severity. However, further testing in a large sample is warranted. This has important implications for prenatal prediction and personalized treatment regimens for infants at highest risk for severe NAS.
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Affiliation(s)
- Elisha M Wachman
- Pediatrics, Boston Medical Center, 771 Albany Street, Dowling 4N 4109, Boston, MA 02118, United States.
| | - Marie J Hayes
- Graduate School of Biomedical Science & Engineering, University of Maine, Orono, ME 04469, United States.
| | - Richard Sherva
- Biomedical Genetics, Boston University School of Medicine, 72 East Concord Street, Boston, MA 02118, United States.
| | - Mark S Brown
- Pediatrics, Eastern Maine Medical Center, 489 State St, Bangor, ME 04401, United States.
| | - Jonathan M Davis
- Pediatrics, The Floating Hospital for Children at Tufts Medical Center, 755 Washington Street, Boston, MA 02116, United States.
| | - Lindsay A Farrer
- Biomedical Genetics, Boston University School of Medicine, 72 East Concord Street, Boston, MA 02118, United States.
| | - David A Nielsen
- Psychology, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, United States.
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504
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Patrick SW, Burke JF, Biel TJ, Auger KA, Goyal NK, Cooper WO. Risk of Hospital Readmission Among Infants With Neonatal Abstinence Syndrome. Hosp Pediatr 2015; 5:513-9. [PMID: 26427919 PMCID: PMC5110214 DOI: 10.1542/hpeds.2015-0024] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Neonatal abstinence syndrome (NAS) is a postnatal drug withdrawal syndrome that may last for months. Our objective was to determine if infants with NAS are at increased risk for hospital readmission compared with uncomplicated term and late preterm newborns. METHODS In this longitudinal retrospective cohort study, administrative data were used for all births from 2006 to 2009 in the New York State Inpatient Database. We identified infants with NAS, born late preterm or uncomplicated term, as independent groups using diagnostic codes and determined readmission rates. We fit a multivariable logistic regression model with 30-day readmission after discharge as the outcome and infant characteristics, clinical morbidities, insurance type, and length of birth hospitalization as predictors. RESULTS From 2006 to 2009 in New York State, 700 613 infants were classified as uncomplicated term, 51 748 were born late preterm, and 1643 infants were diagnosed with NAS. After adjusting for confounders, infants with NAS (odds ratio [OR] 2.49, 95% confidence interval [CI] 1.75-3.55) were more likely than uncomplicated term infants to be readmitted within 30 days of birth hospitalizations. The risk of readmission was similar to late preterm infants (OR 2.26, 95% CI 2.09-2.45). Length of birth hospitalization in days was inversely related to odds of being readmitted within 30 days of birth hospitalization (OR 0.94 95% CI 0.92-0.96). CONCLUSIONS When compared with uncomplicated term infants, infants diagnosed with NAS were more than twice as likely to be readmitted to the hospital. Future research and state-level policies should investigate means to mitigate risk of hospital readmission for infants with NAS.
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Affiliation(s)
- Stephen W Patrick
- Departments of Pediatrics, and Mildred Stahlman Division of Neonatology, Vanderbilt University, Nashville, Tennessee; Vanderbilt Center for Health Services Research, Nashville, Tennessee; Health Policy, and
| | | | - Terry J Biel
- School of Medicine, University of Michigan, Ann Arbor, Michigan; and
| | - Katherine A Auger
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Neera K Goyal
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - William O Cooper
- Departments of Pediatrics, and Vanderbilt Center for Health Services Research, Nashville, Tennessee; Health Policy, and
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505
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Hall ES, Wexelblatt SL, Crowley M, Grow JL, Jasin LR, Klebanoff MA, McClead RE, Meinzen-Derr J, Mohan VK, Stein H, Walsh MC. Implementation of a Neonatal Abstinence Syndrome Weaning Protocol: A Multicenter Cohort Study. Pediatrics 2015; 136:e803-10. [PMID: 26371196 PMCID: PMC9923575 DOI: 10.1542/peds.2015-1141] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/21/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To evaluate the generalizability of stringent protocol-driven weaning in improving total duration of opioid treatment and length of inpatient hospital stay after treatment of neonatal abstinence syndrome (NAS). METHODS We conducted a retrospective cohort analysis of 981 infants who completed pharmacologic treatment of NAS with methadone or morphine from January 2012 through August 2014. Before July 2013, 3 of 6 neonatology provider groups (representing Ohio's 6 children's hospitals) directed NAS nursery care by using group-specific treatment protocols containing explicit weaning guidelines. In July 2013, a standardized weaning protocol was adopted by all 6 groups. Statistical analysis was performed to identify effects of adoption of the multicenter weaning protocol on total duration of opioid treatment and length of hospital stay at the protocol-adopting sites and at the sites with preexisting protocol-driven weaning. RESULTS After adoption of the multicenter protocol, infants treated by the 3 groups previously without stringent weaning guidelines experienced shorter duration of opioid treatment (23.0 vs 34.0 days, P < .001) and length of inpatient hospital stay (23.7 vs 31.6 days, P < .001). Protocol-adopting sites also experienced a lower rate of adjunctive drug therapy (5% vs 21%, P = .004). Outcomes were sustained by the 3 groups who initially had specific weaning guidelines after multicenter adoption (duration of treatment = 17.0 days and length of hospital stay = 23.3 days). CONCLUSIONS Adoption of a stringent weaning protocol resulted in improved NAS outcomes, demonstrating generalizability of the protocol-driven weaning approach. Opportunity remains for additional protocol refinement.
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Affiliation(s)
| | | | - Moira Crowley
- Pediatrics, University Hospitals Rainbow Babies and Children's Hospital and Case Western Reserve University, Cleveland, Ohio
| | - Jennifer L Grow
- Pediatrix Medical Group of Ohio, Akron Children's Hospital, Akron, Ohio
| | - Lisa R Jasin
- Department of Nursing, Dayton Children's Hospital, Dayton, Ohio
| | | | - Richard E McClead
- Department of Neonatology, Nationwide Children's Hospital, Columbus, Ohio; and
| | - Jareen Meinzen-Derr
- Perinatal Institute, and Biostatistics and Epidemiology, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Vedagiri K Mohan
- Department of Neonatology, ProMedica Toledo Children's Hospital, Toledo, Ohio
| | - Howard Stein
- Department of Neonatology, ProMedica Toledo Children's Hospital, Toledo, Ohio
| | - Michele C Walsh
- Pediatrics, University Hospitals Rainbow Babies and Children's Hospital and Case Western Reserve University, Cleveland, Ohio
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506
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Neonatal abstinence syndrome: use of clonazepam? J Perinatol 2015; 35:891. [PMID: 26412405 DOI: 10.1038/jp.2015.49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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507
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508
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Polak K, Haug NA, Drachenberg HE, Svikis DS. Gender Considerations in Addiction: Implications for Treatment. CURRENT TREATMENT OPTIONS IN PSYCHIATRY 2015; 2:326-338. [PMID: 26413454 PMCID: PMC4578628 DOI: 10.1007/s40501-015-0054-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Kathryn Polak
- Virginia Commonwealth University 806 W. Franklin St., P.O. Box 842018, Richmond, VA 23284 804-477-5091,
| | - Nancy A. Haug
- PGSP-Stanford Psy.D. Consortium, Palo Alto University, The Gronowski Center, 5150 El Camino Real, C-24, Los Altos, CA 94022, 650-961-9300, ext. 3616,
| | | | - Dace S. Svikis
- Professor, Department of Psychology, Deputy Director, Institute for Women’s Health, Virginia Commonwealth University, 806 W. Franklin St., P.O. Box 842018, Richmond, VA 23284
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509
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Whelan KT, Heckmann MK, Lincoln PA, Hamilton SM. Pediatric Withdrawal Identification and Management. J Pediatr Intensive Care 2015; 4:73-78. [PMID: 31110855 DOI: 10.1055/s-0035-1556749] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Sedation administered by continuous intravenous infusion is commonly used in the pediatric intensive care unit to facilitate and maintain safe care of children during critical illness. Prolonged use of sedatives, including opioids, benzodiazepines, and potentially other adjunctive agents, is known to cause withdrawal symptoms when they are stopped abruptly or weaned quickly. In this review, the common signs and symptoms of opioid, benzodiazepine, and dexmedetomidine withdrawal will be discussed. Current tools used to measure withdrawal objectively, as well as withdrawal prevention and management strategies, will be discussed.
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Affiliation(s)
- Katherine T Whelan
- Division of Cardiac Intensive Care, Department of Cardiovascular/Critical Care Nursing, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Maura K Heckmann
- Division of Critical Care, Department of Anesthesia, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Patricia A Lincoln
- Department of Cardiovascular/Critical Care Nursing, Cardiovascular Intensive Care Unit, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Susan M Hamilton
- Department of Cardiovascular/Critical Care Nursing, Medical Surgical Intensive Care Unit, Boston Children's Hospital, Boston, Massachusetts, United States
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510
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Ko JY, Farr SL, Tong VT, Creanga AA, Callaghan WM. Prevalence and patterns of marijuana use among pregnant and nonpregnant women of reproductive age. Am J Obstet Gynecol 2015; 213:201.e1-201.e10. [PMID: 25772211 PMCID: PMC7469257 DOI: 10.1016/j.ajog.2015.03.021] [Citation(s) in RCA: 204] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 12/12/2014] [Accepted: 03/10/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The objective of the study was to provide national prevalence, patterns, and correlates of marijuana use in the past month and past 2-12 months among women of reproductive age by pregnancy status. STUDY DESIGN Data from 2007-2012 National Surveys on Drug Use and Health, a cross-sectional nationally representative survey, identified pregnant (n = 4971) and nonpregnant (n = 88,402) women 18-44 years of age. Women self-reported marijuana use in the past month and past 2-12 months (use in the past year but not in the past month). χ(2) statistics and adjusted prevalence ratios were estimated using a weighting variable to account for the complex survey design and probability of sampling. RESULTS Among pregnant women and nonpregnant women, respectively, 3.9% (95% confidence interval [CI], 3.2-4.7) and 7.6% (95% CI, 7.3-7.9) used marijuana in the past month and 7.0% (95% CI, 6.0-8.2) and 6.4% (95% CI, 6.2-6.6) used in the past 2-12 months. Among past-year marijuana users (n = 17,934), use almost daily was reported by 16.2% of pregnant and 12.8% of nonpregnant women; and 18.1% of pregnant and 11.4% of nonpregnant women met criteria for abuse and/or dependence. Approximately 70% of both pregnant and nonpregnant women believe there is slight or no risk of harm from using marijuana once or twice a week. Smokers of tobacco, alcohol users, and other illicit drug users were 2-3 times more likely to use marijuana in the past year than respective nonusers, adjusting for sociodemographic characteristics. CONCLUSION More than 1 in 10 pregnant and nonpregnant women reported using marijuana in the past 12 months. A considerable percentage of women who used marijuana in the past year were daily users, met abuse and/or dependence criteria, and were polysubstance users. Comprehensive screening, treatment for use of multiple substances, and additional research and patient education on the possible harms of marijuana use are needed for all women of reproductive age.
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Affiliation(s)
- Jean Y Ko
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA.
| | - Sherry L Farr
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Van T Tong
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Andreea A Creanga
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - William M Callaghan
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
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511
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Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012. J Perinatol 2015; 35:650-5. [PMID: 25927272 PMCID: PMC4520760 DOI: 10.1038/jp.2015.36] [Citation(s) in RCA: 405] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 02/24/2015] [Accepted: 03/12/2015] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Neonatal abstinence syndrome (NAS), a postnatal opioid withdrawal syndrome, increased threefold from 2000 to 2009. Since 2009, opioid pain reliever prescriptions and complications increased markedly throughout the United States. Understanding recent changes in NAS and its geographic variability would inform state and local governments in targeting public health responses. STUDY DESIGN We utilized diagnostic and demographic data for hospital discharges from 2009 to 2012 from the Kids' Inpatient Database and the Nationwide Inpatient Sample. NAS-associated diagnoses were identified utilizing International Classification of Diseases, Ninth Revision, Clinical Modification codes. All analyses were conducted with nationally weighted data. Expenditure data were adjusted to 2012 US dollars. Between-year differences were determined utilizing least squares regression. RESULTS From 2009 to 2012, NAS incidence increased nationally from 3.4 (95% confidence interval (CI): 3.2 to 3.6) to 5.8 (95% CI 5.5 to 6.1) per 1000 hospital births, reaching a total of 21,732 infants with the diagnosis. Aggregate hospital charges for NAS increased from $732 million to $1.5 billion (P<0.001), with 81% attributed to state Medicaid programs in 2012. NAS incidence varied by geographic census division, with the highest incidence rate (per 1000 hospital births) of 16.2 (95% CI 12.4 to 18.9) in the East South Central Division (Kentucky, Tennessee, Mississippi and Alabama) and the lowest in West South Central Division Oklahoma, Texas, Arkansas and Louisiana 2.6 (95% CI 2.3 to 2.9). CONCLUSION NAS incidence and hospital charges grew substantially during our study period. This costly public health problem merits a public health approach to alleviate harm to women and children. States, particularly, in areas of the country most affected by the syndrome must continue to pursue primary prevention strategies to limit the effects of opioid pain reliever misuse.
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512
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513
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Provenza N, Calpena AC, Mallandrich M, Pueyo B, Clares B. Design of pediatric oral formulations with a low proportion of methadone or phenobarbital for the treatment of neonatal abstinence syndrome. Pharm Dev Technol 2015; 21:755-62. [PMID: 26155877 DOI: 10.3109/10837450.2015.1055765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT Elaboration of oral liquid formulations is the best alternative when no marketed forms are available for pediatrics. OBJECTIVE The development, characterization and stability evaluation of methadone (MI, MII, MIII) and phenobarbital (PI, PII) can be used for the treatment of neonatal abstinence syndrome (NAS). MATERIAL AND METHODS A standard operating procedure was established and parameters such as appearance, pH, rheological behavior and drug content were evaluated at three temperatures for 90 days. RESULTS AND DISCUSSION Changes in color of phenobarbital made necessary the storage below 25 °C. pH did not change in methadone solutions and was able to maintain phenobarbital solubilized. Degradation data at 4 °C fitted to Plateau equation followed by one phase decay. MI was stable for 60 days at the three temperatures; MII for 90 days at 4 and 25 °C and 60 days at 40 °C; MIII for 60 days at 4 °C, 15 days at 25 °C and 7 days at 4 °C. PI was stable for 60 days at 4 °C and 30 days at 25 °C. PII was stable for 7 days at 4 and 25 °C. All solutions met microbial specifications. CONCLUSION A correct dosage for the treatment of NAS was guaranteed.
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Affiliation(s)
- Nora Provenza
- a Pharmacokinetics and Biopharmaceutics Unit , School of Pharmacy, University of Barcelona , Barcelona , Spain and
| | - Ana C Calpena
- a Pharmacokinetics and Biopharmaceutics Unit , School of Pharmacy, University of Barcelona , Barcelona , Spain and
| | - Mireia Mallandrich
- a Pharmacokinetics and Biopharmaceutics Unit , School of Pharmacy, University of Barcelona , Barcelona , Spain and
| | - Blanca Pueyo
- a Pharmacokinetics and Biopharmaceutics Unit , School of Pharmacy, University of Barcelona , Barcelona , Spain and
| | - Beatriz Clares
- b Department of Pharmacy and Pharmaceutical Technology , School of Pharmacy, University of Granada , Granada , Spain
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514
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Ng CM, Dombrowsky E, Lin H, Erlich ME, Moody DE, Barrett JS, Kraft WK. Population Pharmacokinetic Model of Sublingual Buprenorphine in Neonatal Abstinence Syndrome. Pharmacotherapy 2015; 35:670-80. [PMID: 26172282 DOI: 10.1002/phar.1610] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Neonatal abstinence syndrome (NAS)--a clinical entity of infants from in utero exposure to psychoactive xenobiotic and buprenorphine--has been successfully used to treat NAS. However, nothing is known about the pharmacokinetics (PK) of buprenorphine in neonates with NAS. To our knowledge, this is the first study to investigate the population pharmacokinetic of sublingual buprenorphine in neonates with NAS. DESIGN A retrospective population PK analysis of: (1) neonates with NAS treated with sublingual buprenorphine in randomized, double blinded clinical study and (2) data from healthy adults from a previously published pharmacokinetic study. SETTING Neonatal intensive care unit and general clinical research unit. PATIENTS Twenty-four neonates with NAS and five healthy adults. INTERVENTIONS All participants received sublingual buprenorphine per study protocol. MEASUREMENTS AND MAIN RESULTS A total of 303 PK data from 29 neonates and adults were used for model development. A population pharmacokinetic analysis was conducted using a first order conditional estimation with interaction in the NONMEM software program. A two-compartment linear PK model with first-order absorption process best described the pharmacokinetics of sublingual buprenorphine in neonates. The apparent clearance (CL) of buprenorphine was linearly related to body weight and matured with increasing age via two distinct saturated pathways. A typical neonate with NAS (body weight, 2.9 kg; postnatal age; 5.4 days) had a CL of 3.5 L/kg/hour and elimination half-life of 11 hours. Phenobarbital did not affect the clearance of buprenorphine compared to neonates of similar age and weight. CONCLUSIONS This is the first study to investigate the population PK of sublingual buprenorphine in neonatal NAS. To our knowledge, this is also the first report to describe the age-dependent changes of buprenorphine PK in this patient population. No buprenorphine dose adjustment is needed for neonates with NAS treated with buprenorphine and concurrent phenobarbital.
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Affiliation(s)
- Chee M Ng
- Clinical Pharmacology and Therapeutics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Erin Dombrowsky
- Clinical Pharmacology and Therapeutics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Hopi Lin
- Clinical Pharmacology and Therapeutics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michelle E Erlich
- Department of Pediatrics and Neurology, Mt. Sinai School of Medicine, New York, New York
| | - David E Moody
- Center of Human Toxicology, Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, Utah
| | - Jeffrey S Barrett
- Clinical Pharmacology and Therapeutics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Walter K Kraft
- Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, Pennsylvania
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515
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Detection of codeine, morphine, 6-monoacetylmorphine, and meconin in human umbilical cord tissue: method validation and evidence of in utero heroin exposure. Ther Drug Monit 2015; 37:45-52. [PMID: 24901495 PMCID: PMC4297219 DOI: 10.1097/ftd.0000000000000104] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Background: Heroin abuse is a significant public health issue and is on the rise because of the unintended consequences of strengthening controls for nonmedical use of prescription pain killers. Included in this trend is an increase in opiate exposed newborns that are particularly vulnerable to a number of negative health outcomes. Methods: After presenting a fully validated liquid chromatography–tandem mass spectrometric method for codeine, morphine, 6-monoacetylmorphine, and meconin, a metabolite of the heroin contaminant noscapine, we compared the outcome of 46 authentic umbilical specimens with the results generated using a previous less sensitive method that did not include meconin. Additionally, we provided a summary of opiate finding from a year-long survey of specimens received into a commercial reference laboratory. Results: The limits of detection for all 4 compounds were 0.1 ng/g, the limit of quantitation was 0.2 ng/g, and the assay was linear from 0.2 to 10.0 ng/g. Of the 46 comparative specimens, this method improved the identification of heroin exposure from 2 to 5, and the year-long survey identified 86 heroin-exposed newborns with 11 of them identified by the sole identification of meconin. Conclusions: This study demonstrated that a more sensitive analytical platform and the inclusion of meconin in the opiates assay improved the ability to distinguish between in utero heroin exposure and maternal administration of codeine or morphine.
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516
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517
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Krans EE, Cochran G, Bogen DL. Caring for Opioid-dependent Pregnant Women: Prenatal and Postpartum Care Considerations. Clin Obstet Gynecol 2015; 58:370-9. [PMID: 25775440 PMCID: PMC4607033 DOI: 10.1097/grf.0000000000000098] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Pregnancy is an opportune time to identify opioid dependence, facilitate conversion to opioid maintenance treatment, and coordinate care with specialists in addiction medicine, behavioral health, and social services. Comprehensive prenatal care for opioid-dependent women involves the evaluation and the management of co-occurring psychiatric disorders, polysubstance use, infectious diseases, social stressors, and counseling regarding the importance of breastfeeding, contraception, and neonatal abstinence syndrome. Although the complex psychiatric, social, and environmental factors faced by this population pose significant challenges to obstetric care providers, the development of strong patient-provider relationships can facilitate the ability to deliver efficient and effective health care during pregnancy.
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Affiliation(s)
- Elizabeth E Krans
- Departments of *Obstetrics, Gynecology & Reproductive Sciences, Magee-Womens Research Institute ‡Pediatrics †School of Social Work, University of Pittsburgh, Pittsburgh, Pennsylvania
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518
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Tolia VN, Patrick SW, Bennett MM, Murthy K, Sousa J, Smith PB, Clark RH, Spitzer AR. Increasing incidence of the neonatal abstinence syndrome in U.S. neonatal ICUs. N Engl J Med 2015; 372:2118-26. [PMID: 25913111 DOI: 10.1056/nejmsa1500439] [Citation(s) in RCA: 320] [Impact Index Per Article: 35.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The incidence of the neonatal abstinence syndrome, a drug-withdrawal syndrome that most commonly occurs after in utero exposure to opioids, is known to have increased during the past decade. However, recent trends in the incidence of the syndrome and changes in demographic characteristics and hospital treatment of these infants have not been well characterized. METHODS Using multiple cross-sectional analyses and a deidentified data set, we analyzed data from infants with the neonatal abstinence syndrome from 2004 through 2013 in 299 neonatal intensive care units (NICUs) across the United States. We evaluated trends in incidence and health care utilization and changes in infant and maternal clinical characteristics. RESULTS Among 674,845 infants admitted to NICUs, we identified 10,327 with the neonatal abstinence syndrome. From 2004 through 2013, the rate of NICU admissions for the neonatal abstinence syndrome increased from 7 cases per 1000 admissions to 27 cases per 1000 admissions; the median length of stay increased from 13 days to 19 days (P<0.001 for both trends). The total percentage of NICU days nationwide that were attributed to the neonatal abstinence syndrome increased from 0.6% to 4.0% (P<0.001 for trend), with eight centers reporting that more than 20% of all NICU days were attributed to the care of these infants in 2013. Infants increasingly received pharmacotherapy (74% in 2004-2005 vs. 87% in 2012-2013, P<0.001 for trend), with morphine the most commonly used drug (49% in 2004 vs. 72% in 2013, P<0.001 for trend). CONCLUSIONS From 2004 through 2013, the neonatal abstinence syndrome was responsible for a substantial and growing portion of resources dedicated to critically ill neonates in NICUs nationwide.
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Affiliation(s)
- Veeral N Tolia
- From the Division of Neonatology, Department of Pediatrics, Baylor University Medical Center, Pediatrix Medical Group (V.N.T.), and the Office of the Chief Quality Officer, Baylor Scott and White Health (M.M.B.) - all in Dallas; the Mildred Stahlman Division of Neonatology, Department of Pediatrics, and the Vanderbilt Center for Health Services Research and Department of Health Policy, Vanderbilt University School of Medicine, Nashville (S.W.P.); the Division of Neonatology, Department of Pediatrics, Feinberg School of Medicine, Northwestern University, and Ann and Robert H. Lurie Children's Hospital of Chicago - both in Chicago (K.M.); the Department of Biomedical Sciences, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton (J.S.), and the Center for Research, Education, and Quality, Mednax, Sunrise (R.H.C., A.R.S.) - both in Florida; the Department of Pediatrics, Duke University School of Medicine, Durham, NC (P.B.S.); and Pediatrix Medical Group, Greenville Memorial Hospital, Greenville, SC (R.H.C.)
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519
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Nayeri F, Sheikh M, Kalani M, Niknafs P, Shariat M, Dalili H, Dehpour AR. Phenobarbital versus morphine in the management of neonatal abstinence syndrome, a randomized control trial. BMC Pediatr 2015; 15:57. [PMID: 25976238 PMCID: PMC4438473 DOI: 10.1186/s12887-015-0377-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 05/08/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUNDS Evaluating the efficacy of the loading and tapering dose of Phenobarbital versus oral Morphine in the management of NAS. METHODS This randomized, open-label, controlled trial was conducted on 60 neonates born to illicit drugs dependent mothers at Vali-Asr and Akbar-Abadi hospitals, Tehran, Iran, who exhibited NAS requiring medical therapy. The neonates were randomized to receive either: Oral Morphine Sulfate or a loading dose of Phenobarbital followed by a tapering dose. The duration of treatment required for NAS resolution, the total hospital stay and the requirement for additional second line treatment were compared between the treatment groups. RESULTS The Mean ± Standard Deviation for the duration of treatment required for the resolution of NAS was 8.5 ± 5 days in the Morphine group and 8.5 ± 4 days in the Phenobarbital group (P = 0.9). The duration of total hospital stay was 12.6 ± 5.6 days in the Morphine group and 12.5 ± 5.3 days in the Phenobarbital group (P = 0.7). 3.3 % in the Morphine group versus 6.6 % in the Phenobarbital group required adjunctive treatment (P = 0.5). CONCLUSIONS There were no significant differences in the duration of treatment, duration of hospital stay, and the requirement for adjunctive treatment, between the neonates with NAS who received Morphine Sulfate and neonates who received a loading and tapering dose of Phenobarbital. TRIAL REGISTRATION This study is registered at the Iranian Registry of Clinical Trials ( www.irct.ir ) which is a Primary Registry in the WHO Registry Network. (Registration Number = IRCT201406239568N8 ).
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Affiliation(s)
- Fatemeh Nayeri
- Maternal, Fetal and Neonatal Research Center, Tehran University of Medical Sciences, Tehran, Iran.
- Breastfeeding Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mahdi Sheikh
- Maternal, Fetal and Neonatal Research Center, Tehran University of Medical Sciences, Tehran, Iran.
- Breastfeeding Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Majid Kalani
- Department of Neonatology, Akbar-Abadi Hospital, Iran University of Medical Sciences, Tehran, Iran.
| | - Pedram Niknafs
- Pediatrics Department, Kerman University of Medical Sciences, Kerman, Iran.
| | - Mamak Shariat
- Maternal, Fetal and Neonatal Research Center, Tehran University of Medical Sciences, Tehran, Iran.
- Breastfeeding Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Hosein Dalili
- Breastfeeding Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Ahmad-Reza Dehpour
- Department of Pharmacology, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
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520
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Patrick SW, Dudley J, Martin PR, Harrell FE, Warren MD, Hartmann KE, Ely EW, Grijalva CG, Cooper WO. Prescription opioid epidemic and infant outcomes. Pediatrics 2015; 135:842-50. [PMID: 25869370 PMCID: PMC4411781 DOI: 10.1542/peds.2014-3299] [Citation(s) in RCA: 201] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2015] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Although opioid pain relievers are commonly prescribed in pregnancy, their association with neonatal outcomes is poorly described. Our objectives were to identify neonatal complications associated with antenatal opioid pain reliever exposure and to establish predictors of neonatal abstinence syndrome (NAS). METHODS We used prescription and administrative data linked to vital statistics for mothers and infants enrolled in the Tennessee Medicaid program between 2009 and 2011. A random sample of NAS cases was validated by medical record review. The association of antenatal exposures with NAS was evaluated by using multivariable logistic regression, controlling for maternal and infant characteristics. RESULTS Of 112,029 pregnant women, 31,354 (28%) filled ≥ 1 opioid prescription. Women prescribed opioid pain relievers were more likely than those not prescribed opioids (P < .001) to have depression (5.3% vs 2.7%), anxiety disorder (4.3% vs 1.6%) and to smoke tobacco (41.8% vs 25.8%). Infants with NAS and opioid-exposed infants were more likely than unexposed infants to be born at a low birth weight (21.2% vs 11.8% vs 9.9%; P < .001). In a multivariable model, higher cumulative opioid exposure for short-acting preparations (P < .001), opioid type (P < .001), number of daily cigarettes smoked (P < .001), and selective serotonin reuptake inhibitor use (odds ratio: 2.08 [95% confidence interval: 1.67-2.60]) were associated with greater risk of developing NAS. CONCLUSIONS Prescription opioid use in pregnancy is common and strongly associated with neonatal complications. Antenatal cumulative prescription opioid exposure, opioid type, tobacco use, and selective serotonin reuptake inhibitor use increase the risk of NAS.
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Affiliation(s)
- Stephen W Patrick
- Departments of Pediatrics, Mildred Stahlman Division of Neonatology, Vanderbilt University, Nashville, Tennessee; Vanderbilt Center for Health Services Research, Nashville, Tennessee; Health Policy,
| | | | | | | | | | - Katherine E Hartmann
- Vanderbilt Center for Health Services Research, Nashville, Tennessee; Obstetrics and Gynecology, and
| | - E Wesley Ely
- Vanderbilt Center for Health Services Research, Nashville, Tennessee; Medicine, Vanderbilt University, Nashville, Tennessee; Veteran's Affairs, Tennessee Valley Geriatric Research Education Clinical Center, Nashville, Tennessee
| | - Carlos G Grijalva
- Vanderbilt Center for Health Services Research, Nashville, Tennessee; Health Policy, Veteran's Affairs, Tennessee Valley Geriatric Research Education Clinical Center, Nashville, Tennessee
| | - William O Cooper
- Departments of Pediatrics, Vanderbilt Center for Health Services Research, Nashville, Tennessee; Health Policy
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521
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Lardieri AB, Fusco NM, Simone S, Walker LK, Morgan JA, Parbuoni KA. Effects of Clonidine on Withdrawal From Long-term Dexmedetomidine in the Pediatric Patient. J Pediatr Pharmacol Ther 2015; 20:45-53. [PMID: 25859170 DOI: 10.5863/1551-6776-20.1.45] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To compare withdrawal symptoms among pediatric intensive care patients receiving clonidine to those not receiving clonidine while being weaned from long-term dexmedetomidine. METHODS This retrospective analysis evaluated Withdrawal Assessment Tool-1 (WAT-1) scores and hemodynamic parameters in pediatric patients on dexmedetomidine for 5 days or longer between January 1, 2009, and December 31, 2012. The primary objective was to compare withdrawal symptoms based on the number of elevated WAT-1 scores among patients on clonidine to those not on clonidine, while being weaned from long-term dexmedetomidine. The secondary objective was to describe withdrawal symptoms associated with long-term dexmedetomidine use. RESULTS Nineteen patients (median age, 1.5 years; interquartile range [IQR], 0.67-3.3) received 20 treatment courses of dexmedetomidine for at least 5 days. Clonidine was received by patients during 12 of the treatment courses. The patients in the clonidine group had an average of 0.8 (range, 0-6) elevated WAT-1 scores 24 hours post wean compared to an average of 3.2 (0-8) elevated WAT-1 scores in the no clonidine group (p = 0.49). There were no significant difierences between prewean and postwean systolic or diastolic blood pressures among the 2 groups. The average heart rate during the postwean period was 112 beats per minute (bpm) (range, 88.5-151.5) in the clonidine group compared to 138.4 bpm (range, 117.8-168.3) in the no clonidine group (p = 0.003). In the clonidine group, the mean change in heart rate postwean compared to prewean was an increase of 3.6 bpm (range, -39.6 to 47.5), compared to a mean increase of 29.9 bpm (range, 5.5-74.7) in the no clonidine group (p = 0.042). CONCLUSIONS There was no difierence in WAT-1 scores between groups, with the clonidine group displaying a trend towards fewer elevated WAT-1 scores during the 24 hours post dexmedetomidine wean. Patients who received clonidine had significantly lower heart rates than the no clonidine group.
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Affiliation(s)
- Allison B Lardieri
- Department of Pharmacy Practice and Science, School of Pharmacy, University of Maryland, Baltimore, Maryland
| | - Nicholas M Fusco
- School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York
| | - Shari Simone
- Department of Pediatrics, School of Medicine, University of Maryland, Baltimore, Maryland
| | - L Kyle Walker
- Department of Pediatrics, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Jill A Morgan
- Department of Pharmacy Practice and Science, School of Pharmacy, University of Maryland, Baltimore, Maryland
| | - Kristine A Parbuoni
- Department of Pharmacy Practice, School of Pharmacy, Loma Linda University, Loma Linda, California
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522
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Abstract
Neonatal abstinence syndrome (NAS) is reaching epidemic proportions related to perinatal use of opioids. There are many approaches to assess and manage NAS, including one we have outlined. A standardized approach is likely to reduce length of stay and variability in practice. Circumcision is a frequent, painful procedure performed in the neonatal period. The rationale for providing analgesia is presented as well as a review of methods. Pharmacogenomics and pharmacogenetics have expanded our understanding of diseases and their drug therapy. Some applications of pharmacogenomics to the neonatal period are presented, along with pediatric challenges of developmental expression of drug-metabolizing enzymes.
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523
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Beckwith AM, Burke SA. Identification of early developmental deficits in infants with prenatal heroin, methadone, and other opioid exposure. Clin Pediatr (Phila) 2015; 54:328-35. [PMID: 25189695 DOI: 10.1177/0009922814549545] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Study aims to examine development in infants following prenatal heroin, methadone, and opioid exposure, which adversely affects central and autonomic nervous systems. Abrupt discontinuation results in neurologic and behavioral findings as Neonatal Abstinence Syndrome (NAS). METHOD Following NAS treatment, 28 infants (mean age 55 days [range 21-98 days], 57% male) were assessed using Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) Cognitive, Language, and Motor subscales. Outcomes were compared with a historical control. RESULTS Mean Language and Cognition scores were significantly lower (P < .001) in the NAS group. Distributions of scores for Language (P < .001) and Cognition (P = .022) were also significantly different between NAS and historical control groups. CONCLUSION Prenatal heroin, methadone, and other opioid exposure is associated with weaknesses in language and cognition. This information has important public health implications, drawing attention to an otherwise healthy infant population which may benefit from early intervention services.
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Affiliation(s)
- Anna Malia Beckwith
- Children's Specialized Hospital, Rutgers-Robert Wood Johnson Medical School, Mountainside, NJ, USA
| | - Sharon A Burke
- Children's Specialized Hospital, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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524
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Methadone versus morphine for treatment of neonatal abstinence syndrome: a prospective randomized clinical trial. J Perinatol 2015; 35:278-83. [PMID: 25357093 DOI: 10.1038/jp.2014.194] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 08/19/2014] [Accepted: 08/26/2014] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Compare duration of treatment of neonatal abstinence syndrome between methadone and morphine. STUDY DESIGN A prospective, double-masked, randomized trial at a single site. Randomization of methadone or morphine was stratified for maternal treatment with methadone or buprenorphine. Inclusion criteria were (i) maternal treatment with prescribed methadone or buprenorphine, (ii) withdrawal treatment criteria, (iii) adjusted gestational age ⩾35(0/7) weeks and (iv) medically stable. Primary outcome was length of opioid treatment. RESULT From January 2011 through October 2012, 78 infants were eligible for the study: 41 methadone-exposed and 37 buprenorphine-exposed. Consent was obtained from 31 mothers, 13/41 (32%) methadone-treated and 18/37 (49%) buprenorphine-treated. Length of opioid treatment was significantly shorter for methadone than morphine treatment, median 14 versus 21 days (P=0.008). CONCLUSION Methadone had a shorter length of neonatal withdrawal treatment compared with morphine. Owing to the smaller sample size and single site, a larger randomized study is needed.
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525
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Lefevere J, Allegaert K. Question: is breastfeeding useful in the management of neonatal abstinence syndrome? Arch Dis Child 2015; 100:414-5. [PMID: 25784740 DOI: 10.1136/archdischild-2015-308275] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Julie Lefevere
- Department of Development and Regeneration, KU Leuven, Belgium Neonatal Intensive Care Unit, University Hospitals Leuven, Belgium
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Belgium Neonatal Intensive Care Unit, University Hospitals Leuven, Belgium
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526
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Kieviet N, Hoppenbrouwers C, Dolman KM, Berkhof J, Wennink H, Honig A. Risk factors for poor neonatal adaptation after exposure to antidepressants in utero. Acta Paediatr 2015; 104:384-91. [PMID: 25559357 DOI: 10.1111/apa.12921] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 09/19/2014] [Accepted: 12/30/2014] [Indexed: 12/01/2022]
Abstract
AIM Infants exposed to antidepressants in utero are at risk of developing poor neonatal adaptation (PNA). This study identified risk factors for PNA. METHODS In this cohort study, data on mothers and infants admitted to the maternity ward of a general hospital between 2007 and 2012 were analysed. All infants were exposed to an antidepressant during the last trimester of foetal life. The main outcome measure was PNA, defined as at least one Finnegan scores of four or more during admission. Risk factors analysed for their possible association with PNA included type of feeding, type and dosage of antidepressant, prematurity and maternal smoking, anxiety and depression. RESULTS We included 247 infants in the study and 157 (64%) developed PNA. Formula feeding was associated with an increased risk of PNA compared to breastfeeding or mixed feeding (OR 3.16 95% CI 1.40-7.13 p = 0.003). Selective serotonin reuptake inhibitors (SSRIs) were associated with an increased risk of PNA compared to serotonin and noradrenaline reuptake inhibitors (OR 2.52 95% CI 1.07-5.95 p = 0.04). Dosage did not influence the risk of PNA (OR 1.50 95% CI 0.89-2.52 p = 0.13). CONCLUSION Formula feeding and exposure to SSRIs were associated with development of PNA, but dosage was not.
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Affiliation(s)
- Noera Kieviet
- Department of Paediatrics; Sint Lucas Andreas Hospital; Amsterdam The Netherlands
| | - Chris Hoppenbrouwers
- Department of Paediatrics; Sint Lucas Andreas Hospital; Amsterdam The Netherlands
| | - Koert M Dolman
- Department of Paediatrics; Sint Lucas Andreas Hospital; Amsterdam The Netherlands
| | - Johannes Berkhof
- Department of Epidemiology and Biostatistics; VU Medical Centre; Amsterdam The Netherlands
| | - Hanneke Wennink
- Department of Paediatrics; Sint Lucas Andreas Hospital; Amsterdam The Netherlands
| | - Adriaan Honig
- Department of Psychiatry; Sint Lucas Andreas Hospital; Amsterdam The Netherlands
- Department of Psychiatry; VU Medical Centre; Amsterdam The Netherlands
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527
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Yazdy MM, Desai RJ, Brogly SB. Prescription Opioids in Pregnancy and Birth Outcomes: A Review of the Literature. J Pediatr Genet 2015; 4:56-70. [PMID: 26998394 PMCID: PMC4795985 DOI: 10.1055/s-0035-1556740] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 02/05/2015] [Indexed: 12/29/2022]
Abstract
Prescription opioids are used prenatally for the management of pain, as well as for opiate dependency. Opioids are known to cross the placenta and despite the evidence of possible adverse effects on fetal development, studies have consistently shown prescription opioids are among the most commonly prescribed medications and the prevalence of use is increasing among pregnant women. This article summarizes the available literature documenting potential harms associated with prescription opioid use during pregnancy, including poor fetal growth, preterm birth, birth defects, and neonatal abstinence syndrome.
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Affiliation(s)
- Mahsa M. Yazdy
- Slone Epidemiology Center at Boston University, Boston, Massachusetts, United States
| | - Rishi J. Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Susan B. Brogly
- Department of Medicine and Surgery, Queen's University, Kingston, Ontario, Canada
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528
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Lee J, Hulman S, Musci M, Stang E. Neonatal Abstinence Syndrome: Influence of a Combined Inpatient/Outpatient Methadone Treatment Regimen on the Average Length of Stay of a Medicaid NICU Population. Popul Health Manag 2015; 18:392-7. [PMID: 25803316 PMCID: PMC4675180 DOI: 10.1089/pop.2014.0134] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Prescription opioid and heroin abuse have been increasing steadily year after year, and continue to be a serious national problem. A sequela of the increase in opioid abuse has been an increase in the number of infants born with opioid dependence. These infants often require costly, prolonged stays in the neonatal intensive care unit (NICU) for drug withdrawal treatment. The authors studied a population of infants from a large Medicaid health plan who were born with neonatal abstinence syndrome (NAS) secondary to in utero opioid exposure to assess the average length of stay in the NICU, and to determine the variables that may account for differences in interinstitutional lengths of stay. The overall average length of stay for NAS was 21.1 days for the 139 infants included in the study. Analysis of the medication used for treatment revealed that infants who were treated with a combined inpatient/outpatient regimen with methadone had an average length of stay of 11.4 days versus 25.1 days for infants who were treated entirely as inpatients (P<0.001), a 55% reduction in average length of stay. In 2009 there were an estimated 13,600 cases of NAS in the United States at a cost of $53,000 per case. A 55% reduction in length of stay corresponds to $396 million in annual savings for the treatment of NAS. Development of successful combined inpatient/outpatient management programs for NAS warrants further consideration. (Population Health Management 2015;18:392–397)
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Affiliation(s)
- Jerry Lee
- 1 ProgenyHealth , Plymouth Meeting, Pennsylvania
| | - Sonia Hulman
- 1 ProgenyHealth , Plymouth Meeting, Pennsylvania
| | | | - Ellen Stang
- 1 ProgenyHealth , Plymouth Meeting, Pennsylvania
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529
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Kreitinger C, Gutierrez H, Hamidovic A, Schmitt C, Sarangarm P, Rayburn WF, Leeman L, Bakhireva LN. The effect of prenatal alcohol co-exposure on neonatal abstinence syndrome in infants born to mothers in opioid maintenance treatment. J Matern Fetal Neonatal Med 2015; 29:783-8. [PMID: 25758627 DOI: 10.3109/14767058.2015.1018168] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE This study examined the effects of prenatal alcohol exposure (PAE) on the incidence and severity of neonatal abstinence syndrome (NAS). STUDY DESIGN For this pilot study, 70 pregnant women on opioid maintenance therapy (OMT) were recruited from a perinatal substance abuse clinic. Subjects were categorized into three study groups based on the timing of alcohol use during pregnancy as assessed by repeated self-reported measures and a comprehensive panel of ethanol biomarkers. NAS outcomes included: duration of hospital stay, the need for pharmacological treatment of NAS, newborn age at the initiation of NAS treatment, duration of treatment and cumulative methadone dose administered. RESULTS The study included a large proportion of ethnic minorities (81.4% Hispanic, 5.7% American Indian), women with less than a high school education (52.2%) and unplanned pregnancy (82.9%). In multivariate analysis, PAE was not associated with NAS outcomes; however, one newborn diagnosed with fetal alcohol syndrome (FAS) demonstrated much more severe NAS compared to other PAE infants. Interestingly, 3rd trimester PAE was associated with a higher prevalence of microcephaly (62.5%) compared to the PAE abstaining group (36.8%; p = 0.08). CONCLUSION In this study, PAE was not associated with NAS severity; however, further examination in a larger study is needed.
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Affiliation(s)
- Christine Kreitinger
- a Department of Pharmacy Practice and Administrative Sciences , College of Pharmacy and
| | - Hilda Gutierrez
- a Department of Pharmacy Practice and Administrative Sciences , College of Pharmacy and
| | - Ajna Hamidovic
- a Department of Pharmacy Practice and Administrative Sciences , College of Pharmacy and
| | - Cheryl Schmitt
- a Department of Pharmacy Practice and Administrative Sciences , College of Pharmacy and.,b Department of Family and Community Medicine , School of Medicine, University of New Mexico , Albuquerque , NM , USA
| | - Preeyaporn Sarangarm
- c Department of Pharmacy , University of New Mexico Hospital , Albuquerque , NM , USA , and
| | - William F Rayburn
- d Department of Obstetrics and Gynecology , School of Medicine, University of New Mexico , Albuquerque , NM , USA
| | - Lawrence Leeman
- b Department of Family and Community Medicine , School of Medicine, University of New Mexico , Albuquerque , NM , USA .,d Department of Obstetrics and Gynecology , School of Medicine, University of New Mexico , Albuquerque , NM , USA
| | - Ludmila N Bakhireva
- a Department of Pharmacy Practice and Administrative Sciences , College of Pharmacy and.,b Department of Family and Community Medicine , School of Medicine, University of New Mexico , Albuquerque , NM , USA
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530
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Wexelblatt SL, Ward LP, Torok K, Tisdale E, Meinzen-Derr JK, Greenberg JM. Universal maternal drug testing in a high-prevalence region of prescription opiate abuse. J Pediatr 2015; 166:582-6. [PMID: 25454935 DOI: 10.1016/j.jpeds.2014.10.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 09/02/2014] [Accepted: 10/01/2014] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate the efficacy of a universal maternal drug testing protocol for all mothers in a community hospital setting that experienced a 3-fold increase in neonatal abstinence syndrome (NAS) over the previous 5 years. STUDY DESIGN We conducted a retrospective cohort study between May 2012 and November 2013 after the implementation of universal maternal urine drug testing. All subjects with positive urine tests were reviewed to identify a history or suspicion of drug use, insufficient prenatal care, placental abruption, sexually transmitted disease, or admission from a justice center, which would have prompted urine testing using our previous risk-based screening guidelines. We also reviewed the records of infants born to mothers with a positive toxicology for opioids to determine whether admission to the special care nursery was required. RESULTS Out of the 2956 maternal specimens, 159 (5.4%) positive results were recorded. Of these, 96 were positive for opioids, representing 3.2% of all maternity admissions. Nineteen of the 96 (20%) opioid-positive urine tests were recorded in mothers without screening risk factors. Seven of these 19 infants (37%) required admission to the special care nursery for worsening signs of NAS, and 1 of these 7 required pharmacologic treatment. CONCLUSION Universal maternal drug testing improves the identification of infants at risk for the development of NAS. Traditional screening methods underestimate in utero opioid exposure.
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Affiliation(s)
- Scott L Wexelblatt
- Division of Neonatology, Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Family Birthing Center, Mercy Anderson Hospital, Cincinnati, OH.
| | - Laura P Ward
- Division of Neonatology, Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Family Birthing Center, Mercy Anderson Hospital, Cincinnati, OH
| | - Kimberly Torok
- Family Birthing Center, Mercy Anderson Hospital, Cincinnati, OH
| | | | - Jareen K Meinzen-Derr
- Division of Neonatology, Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - James M Greenberg
- Division of Neonatology, Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Family Birthing Center, Mercy Anderson Hospital, Cincinnati, OH
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531
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Challenges in managing acute on chronic pain in a pregnant woman at high risk for opioid use disorder in the general hospital setting. Harv Rev Psychiatry 2015; 23:157-66. [PMID: 25747928 DOI: 10.1097/hrp.0000000000000080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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532
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Abstract
Neonatal opioid withdrawal syndrome is common due to the current opioid addiction epidemic. Infants born to women covertly abusing prescription opioids may not be identified as at risk until withdrawal signs present. Buprenorphine is a newer treatment for maternal opioid addiction and appears to result in a milder withdrawal syndrome than methadone. Initial treatment is with nonpharmacological measures including decreasing stimuli, however pharmacological treatment is commonly required. Opioid monotherapy is preferred, with phenobarbital or clonidine uncommonly needed as adjunctive therapy. Rooming-in and breastfeeding may decease the severity of withdrawal. Limited evidence is available regarding long-term effects of perinatal opioid exposure.
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533
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Bada HS, Sithisarn T, Gibson J, Garlitz K, Caldwell R, Capilouto G, Li Y, Leggas M, Breheny P. Morphine versus clonidine for neonatal abstinence syndrome. Pediatrics 2015; 135:e383-91. [PMID: 25624389 DOI: 10.1542/peds.2014-2377] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The study goal was to determine whether clonidine treatment of neonatal abstinence syndrome (NAS) would result in a better neurobehavioral performance compared with morphine. METHODS This pilot study prospectively enrolled infants ≥ 35 weeks' gestational age admitted for treatment of NAS. After informed consent was obtained, infants were randomized to receive morphine (0.4 mg/kg per day) or clonidine (5 μg/kg per day) divided into 8 doses. A 25% dose escalation every 24 hours was possible per protocol (maximum of 1 mg/kg per day for morphine and 12 μg/kg per day for clonidine). After control of symptoms, the dose was tapered by 10% every other day. Clinical staff monitored infants by using Finnegan scoring. Masked research staff administered the NICU Network Neurobehavioral Scale (NNNS) at 1 week and at 2 to 4 weeks after initiation of treatment and the Bayley Scales III, and Preschool Language Scale IV, at 1-year adjusted age. Analyses included descriptive statistics, repeated measures analysis of variance, and Wilcoxon tests. RESULTS Infants treated with morphine (n = 15) versus clonidine (n = 16) did not differ in birth weight or age at treatment. Treatment duration was significantly longer for morphine (median 39 days) than for clonidine (median 28 days; P = .02). NNNS summary scores improved significantly with clonidine but not with morphine. On subsequent assessment, those receiving clonidine had lower height of arousal and excitability (P < .05). One-year motor, cognitive, and language scores did not differ between groups. CONCLUSIONS Clonidine may be a favorable alternative to morphine as a single-drug therapy for NAS. A multicenter randomized trial is warranted.
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Affiliation(s)
| | | | - Julia Gibson
- Department of Pharmacy, Kentucky Children's Hospital, Lexington, Kentucky; and
| | - Karen Garlitz
- Department of Pharmacy, Kentucky Children's Hospital, Lexington, Kentucky; and
| | | | | | - Yinglei Li
- Statistics, College of Arts and Sciences and
| | - Markos Leggas
- Pharmaceutical Sciences, College of Pharmacy, University of Kentucky, Lexington, Kentucky
| | - Patrick Breheny
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, Iowa
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534
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535
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536
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Goodman DJ, Milliken CU, Theiler RN, Nordstrom BR, Akerman SC. A Multidisciplinary Approach to the Treatment of Co-occurring Opioid Use Disorder and Posttraumatic Stress Disorder in Pregnancy: A Case Report. J Dual Diagn 2015; 11:248-57. [PMID: 26457976 PMCID: PMC4762276 DOI: 10.1080/15504263.2015.1104484] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Perinatal opioid use disorders negatively impact maternal and neonatal outcomes and are a public health problem of increasing severity. More than half of women with a substance use disorder have a history of posttraumatic stress disorder that, if not adequately addressed, can impede substance use disorder treatment. This case report describes complexities in the treatment of a pregnant woman with opioid use disorder and posttraumatic stress disorder and reviews the psychotherapeutic and pharmacologic approaches available to treat these co-occurring disorders in pregnancy. This case demonstrates the importance of early screening and intervention for co-occurring posttraumatic stress disorder in pregnant women who use substances in a closely coordinated, multidisciplinary approach to improve outcomes for women and their infants.
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Affiliation(s)
- Daisy J Goodman
- a Department of Obstetrics and Gynecology , Dartmouth-Hitchcock Medical Center and Geisel School of Medicine , Lebanon , New Hampshire , USA
| | - Catherine U Milliken
- b Department of Psychiatry , Geisel School of Medicine at Dartmouth , Lebanon , New Hampshire , USA
| | - Regan N Theiler
- a Department of Obstetrics and Gynecology , Dartmouth-Hitchcock Medical Center and Geisel School of Medicine , Lebanon , New Hampshire , USA
| | - Benjamin R Nordstrom
- b Department of Psychiatry , Geisel School of Medicine at Dartmouth , Lebanon , New Hampshire , USA
| | - Sarah C Akerman
- b Department of Psychiatry , Geisel School of Medicine at Dartmouth , Lebanon , New Hampshire , USA
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537
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Turner SD, Gomes T, Camacho X, Yao Z, Guttmann A, Mamdani MM, Juurlink DN, Dhalla IA. Neonatal opioid withdrawal and antenatal opioid prescribing. CMAJ Open 2015; 3:E55-61. [PMID: 25844370 PMCID: PMC4382031 DOI: 10.9778/cmajo.20140065] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The incidence of neonatal opioid withdrawal is increasing in both Canada and the United States. However, the degree to which the treatment of pain with opioids, rather than the misuse of prescription opioids or heroin, contributes to the prevalence of neonatal opioid withdrawal remains unknown. METHODS We conducted a retrospective, population-based, cross-sectional study between 1992 and 2011 in Ontario with 2 objectives. First, we determined the annual incidence of neonatal abstinence syndrome. Second, using data from a subset of women eligible for publicly funded prescription drugs, we determined what proportion of women who deliver an infant with neonatal abstinence syndrome were given a prescription for an opioid before and during pregnancy. RESULTS The incidence of neonatal abstinence syndrome in Ontario increased 15-fold during the study period, from 0.28 per 1000 live births in 1992 to 4.29 per 1000 live births in 2011. During the final 5 years of the study, we identified 927 deliveries of infants with neonatal abstinence syndrome to mothers who were public drug plan beneficiaries. Of these mothers, 67% had received an opioid prescription in the 100 days preceding delivery, including 53.3% who received methadone, an increase from 28.6% in the interval spanning 1 to 2 years before delivery (p < 0.001). Prescription for nonmethadone opioids decreased from 38% to 17% (p < 0.001). INTERPRETATION The incidence of neonatal opioid withdrawal in Ontario has increased substantially over the last 20 years. Most of the women in this cohort who delivered an infant with neonatal abstinence syndrome had received a prescription for an opioid both before and during their pregnancy.
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Affiliation(s)
- Suzanne D Turner
- Department of Family and Community Medicine, St. Michael's Hospital
| | - Tara Gomes
- Li KaShing Knowledge Institute, St. Michael's Hospital ; Leslie Dan Faculty of Pharmacy, University of Toronto
| | | | - Zhan Yao
- Institute for Clinical Evaluative Sciences
| | - Astrid Guttmann
- Institute for Clinical Evaluative Sciences ; Division of Paediatric Medicine, Hospital for Sick Children ; Institute of Health Policy, Management and Evaluation, University of Toronto
| | - Muhammad M Mamdani
- Li KaShing Knowledge Institute, St. Michael's Hospital ; Leslie Dan Faculty of Pharmacy, University of Toronto
| | - David N Juurlink
- Institute for Clinical Evaluative Sciences ; Department of Medicine, University of Toronto ; Sunnybrook Research Institute, Toronto, Ont
| | - Irfan A Dhalla
- Institute for Clinical Evaluative Sciences ; Department of Medicine, University of Toronto ; Department of Medicine, St. Michael's Hospital
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538
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O'Connor AB, O'Brien L, Alto WA, Wong J. Does concurrent in utero exposure to buprenorphine and antidepressant medications influence the course of neonatal abstinence syndrome? J Matern Fetal Neonatal Med 2014; 29:112-4. [PMID: 25394611 DOI: 10.3109/14767058.2014.987750] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To determine whether concurrent in utero exposure to buprenorphine and antidepressants impacts the course of neonatal abstinence syndrome (NAS) in infants. METHODS A retrospective cohort study of 148 infants who were exposed to buprenorphine during pregnancy. Univariate and bivariate analyses were used to examine associations between concurrent maternal use of buprenorphine and antidepressants as compared to maternal use of buprenorphine alone. RESULTS The time to onset of NAS resolution was significantly longer in infants exposed to both buprenorphine and antidepressants during pregnancy when compared to those exposed to buprenorphine alone (129.8 h versus 70.2 h, p = 0.042). CONCLUSIONS Women who are prescribed both antidepressants and buprenorphine during pregnancy should be counseled about the possibility of a prolonged course of neonatal abstinence syndrome.
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Affiliation(s)
- Alane B O'Connor
- a Dartmouth Medical School, Maine Dartmouth Family Medicine Residency , Waterville , ME , USA
| | - Liam O'Brien
- b Department of Mathematics and Statistics , Colby College , Waterville , ME , USA .,c School of Community and Population Health, University of New England , Portland , ME , USA , and
| | - William A Alto
- d Swedish Family Medicine Residency Program Cherry Hill, University of Washington , Seattle , WA , USA
| | - Jacqueline Wong
- d Swedish Family Medicine Residency Program Cherry Hill, University of Washington , Seattle , WA , USA
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539
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Raith W, Urlesberger B. Laser Acupuncture as An Adjuvant Therapy for a Neonate with Neonatal Abstinence Syndrome (Nas) Due to Maternal Substitution Therapy: Additional Value of Acupuncture. Acupunct Med 2014; 32:523-4. [DOI: 10.1136/acupmed-2014-010638] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Wolfgang Raith
- Division of Neonatology, Department of Paediatrics, Medical University of Graz, Graz, Austria
- Research Group for Paediatric Traditional Chinese Medicine, TCM Research Centre Graz (Acupuncture Research), Medical University of Graz, Graz, Austria
| | - Berndt Urlesberger
- Division of Neonatology, Department of Paediatrics, Medical University of Graz, Graz, Austria
- Research Group for Paediatric Traditional Chinese Medicine, TCM Research Centre Graz (Acupuncture Research), Medical University of Graz, Graz, Austria
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540
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Evidence-based nurse-driven interventions for the care of newborns with neonatal abstinence syndrome. Adv Neonatal Care 2014; 14:376-80. [PMID: 25068529 DOI: 10.1097/anc.0000000000000118] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Neonatal abstinence syndrome (NAS) is a growing problem in the United States, related to increased maternal substance use and abuse, and a set of drug withdrawal symptoms that can affect the central nervous system and gastrointestinal and respiratory systems in the newborn when separated from the placenta at birth. Infants with NAS often require a significant length of stay in the neonatal intensive care unit (NICU). Pharmacologic treatments and physician-directed interventions are well researched, but nursing-specific interventions and recommendations are lacking. A thorough review and analysis of the literature and interviews with neonatal experts guided the development of a nursing clinical practice guideline for infants with NAS in a level IV NICU. Recommended nursing-specific interventions include methods for maternal drug-use identification, initiation and timing of the Finnegan Scoring System to monitor withdrawal symptoms, and bedside interventions to lessen the drug-withdrawal symptoms in the newborn with NAS.
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541
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Kieviet N, van Ravenhorst M, Dolman KM, van de Ven PM, Heres M, Wennink H, Honig A. Adapted Finnegan scoring list for observation of anti-depressant exposed infants. J Matern Fetal Neonatal Med 2014; 28:2010-4. [DOI: 10.3109/14767058.2014.977247] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Noera Kieviet
- Department of Paediatrics, Psychiatry Obstetrics Paediatrics Expert Centre Sint Lucas Andreas Hospital, Amsterdam, The Netherlands,
| | - Mariëtte van Ravenhorst
- Department of Paediatrics, Psychiatry Obstetrics Paediatrics Expert Centre Sint Lucas Andreas Hospital, Amsterdam, The Netherlands,
| | - Koert M. Dolman
- Department of Paediatrics, Psychiatry Obstetrics Paediatrics Expert Centre Sint Lucas Andreas Hospital, Amsterdam, The Netherlands,
| | - Peter M. van de Ven
- Department of Epidemiology and Biostatistics, VU University Medical Centre, Amsterdam, The Netherlands,
| | | | - Hanneke Wennink
- Department of Paediatrics, Psychiatry Obstetrics Paediatrics Expert Centre Sint Lucas Andreas Hospital, Amsterdam, The Netherlands,
| | - Adriaan Honig
- Department of Psychiatry, Psychiatry Obstetrics Paediatrics Expert Centre Sint Lucas Andreas Hospital, Amsterdam, The Netherlands, and
- Department of Psychiatry, VU University Medical Centre, Amsterdam, The Netherlands
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542
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Nagiub M, Alton K, Avula V, Hagglund K, Anne P. Heart rate variability evaluation in the assessment and management of in-utero drug-exposed infants. SAGE Open Med 2014; 2:2050312114556525. [PMID: 26770748 PMCID: PMC4607234 DOI: 10.1177/2050312114556525] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 10/01/2014] [Indexed: 11/23/2022] Open
Abstract
Aim: To determine whether heart rate variability parameters vary between in-utero drug-exposed infants and controls. To determine correlations between Finnegan score and heart rate variability parameters. To differentiate those drug-exposed infants who require treatment from those infants who do not. Methods: A total of 24 jaundiced control subjects and 25 in-utero drug-exposed infants were enrolled. The Finnegan score and an electrocardiographic rhythm strip were obtained at 4-h intervals. RR intervals (time between consecutive R waves) were manually tabulated from the rhythm strip and analyzed. Time-domain heart rate variability parameters were calculated and analyzed for both groups. Results: Heart rate variability parameters were cumulatively lower over 3 days in in-utero drug-exposed infants compared with controls (p < 0.05). Root mean square of differences of standard deviation of RR intervals on first day of life, and standard deviation of RR intervals, percentage of consecutive RR intervals greater than 50 ms, and root mean square of differences of standard deviation of RR intervals on the second day of life were significantly lower between in-utero drug-exposed infants and control infants. Three out of five parameters were significantly lower in in-utero drug-exposed infants pre-treatment versus post-treatment (p = 0.001, p = 0.0001, and p = 0.021, respectively). Root mean square of differences of standard deviation of RR intervals was able to differentiate in-utero drug-exposed infants requiring opiate therapy and in-utero drug-exposed infants that did not (p = 0.02). Conclusion: Heart rate variability analysis can contribute to the management of in-utero drug-exposed infants. Heart rate variability could be used in dose titration.
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Affiliation(s)
- Mohamed Nagiub
- Department of Pediatric Cardiology, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, USA
| | - Karen Alton
- Department of Pediatrics, St. John Providence Children's Hospital, Detroit, MI, USA
| | - Varun Avula
- Lake Erie College of Osteopathic Medicine, Erie, PA, USA
| | - Karen Hagglund
- Graduate Medical Education, St. John Hospital & Medical Center, Detroit, MI, USA
| | - Premchand Anne
- Department of Pediatric Cardiology, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, USA; Division of Pediatric Cardiology, Department of Pediatrics, St. John Providence Children's Hospital, Detroit, MI, USA
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543
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Picchietti DL, Hensley JG, Bainbridge JL, Lee KA, Manconi M, McGregor JA, Silver RM, Trenkwalder C, Walters AS. Consensus clinical practice guidelines for the diagnosis and treatment of restless legs syndrome/Willis-Ekbom disease during pregnancy and lactation. Sleep Med Rev 2014; 22:64-77. [PMID: 25553600 DOI: 10.1016/j.smrv.2014.10.009] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 10/27/2014] [Accepted: 10/28/2014] [Indexed: 11/30/2022]
Abstract
Restless legs syndrome (RLS)/Willis-Ekbom disease (WED) is common during pregnancy, affecting approximately one in five pregnant women in Western countries. Many report moderate or severe symptoms and negative impact on sleep. There is very little information in the medical literature for practitioners on the management of this condition during pregnancy. Accordingly, a task force was chosen by the International RLS Study Group (IRLSSG) to develop guidelines for the diagnosis and treatment of RLS/WED during pregnancy and lactation. A committee of nine experts in RLS/WED and/or obstetrics developed a set of 12 consensus questions, conducted a literature search, and extensively discussed potential guidelines. Recommendations were approved by the IRLSSG executive committee, reviewed by IRLSSG membership, and approved by the WED Foundation Medical Advisory Board. These guidelines address diagnosis, differential diagnosis, clinical course, and severity assessment of RLS/WED during pregnancy and lactation. Nonpharmacologic approaches, including reassurance, exercise and avoidance of exacerbating factors, are outlined. A rationale for iron supplementation is presented. Medications for RLS/WED are risk/benefit rated for use during pregnancy and lactation. A few are rated "may be considered" when RLS/WED is refractory to more conservative approaches. An algorithm summarizes the recommendations. These guidelines are intended to improve clinical practice and promote further research.
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Affiliation(s)
- Daniel L Picchietti
- University of Illinois College of Medicine at Urbana-Champaign and Carle Foundation Hospital, Urbana, IL, USA.
| | | | - Jacquelyn L Bainbridge
- Department of Clinical Pharmacy and Department of Neurology, University of Colorado Denver, Aurora, CO, USA
| | - Kathryn A Lee
- Department of Family Health Care Nursing, School of Nursing, University of California San Francisco, San Francisco, CA, USA
| | - Mauro Manconi
- Sleep and Epilepsy Center, Neurocenter of Southern Switzerland, Civic Hospital of Lugano, Lugano, Switzerland
| | - James A McGregor
- Department of Obstetrics and Gynecology, Women's and Children's Hospital, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
| | - Claudia Trenkwalder
- Paracelsus-Elena Hospital, Center of Parkinsonism and Movement Disorders, Kassel, Germany; Department of Neurosurgery, University Medical Center, Goettingen, Germany
| | - Arthur S Walters
- Department of Neurology Vanderbilt University School of Medicine, Nashville, TN, USA
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544
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Rausgaard NL, Ibsen IO, Jørgensen JS, Lamont RF, Ravn P. Prevalence of substance abuse in pregnancy among Danish women. Acta Obstet Gynecol Scand 2014; 94:215-9. [DOI: 10.1111/aogs.12528] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 10/13/2014] [Indexed: 01/09/2023]
Affiliation(s)
- Nete L.K. Rausgaard
- Department of Gynecology and Obstetrics; University of Southern Denmark; Odense University Hospital; Odense Denmark
| | - Inge O. Ibsen
- Department of Gynecology and Obstetrics; University of Southern Denmark; Odense University Hospital; Odense Denmark
| | - Jan S. Jørgensen
- Department of Gynecology and Obstetrics; University of Southern Denmark; Odense University Hospital; Odense Denmark
| | - Ronald F. Lamont
- Department of Gynecology and Obstetrics; University of Southern Denmark; Odense University Hospital; Odense Denmark
| | - Pernille Ravn
- Department of Gynecology and Obstetrics; University of Southern Denmark; Odense University Hospital; Odense Denmark
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545
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Variation in treatment of neonatal abstinence syndrome in US children's hospitals, 2004-2011. J Perinatol 2014; 34:867-72. [PMID: 24921412 DOI: 10.1038/jp.2014.114] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 03/11/2014] [Accepted: 05/05/2014] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Neonatal abstinence syndrome (NAS) is a drug withdrawal syndrome experienced by opioid-exposed infants. There is no standard treatment for NAS and surveys suggest wide variation in pharmacotherapy for NAS. Our objective was to determine whether different pharmacotherapies for NAS are associated with differences in outcomes and to determine whether pharmacotherapy and outcome vary by hospital. STUDY DESIGN We used the Pediatric Health Information System Database from 2004 to 2011 to identify a cohort of infants with NAS requiring pharmacotherapy. Mixed effects hierarchical negative binomial models evaluated the association between pharmacotherapy and hospital with length of stay (LOS), length of treatment (LOT) and hospital charges, after adjusting for socioeconomic variables and comorbid clinical conditions. RESULT Our cohort included 1424 infants with NAS from 14 children's hospitals. Among hospitals in our sample, six used morphine, six used methadone and two used phenobarbital as primary initial treatment for NAS. In multivariate analysis, when compared with NAS patients initially treated with morphine, infants treated with methadone had shorter LOT (incidence rate ratio (IRR) = 0.55; P < 0.0001) and LOS (IRR = 0.60; P < 0.0001). Phenobarbital as a second-line agent was associated with increased LOT (IRR = 2.09; P<0.0001), LOS (IRR = 1.78; P < 0.0001) and higher hospital charges (IRR = 1.84; P < 0.0001). After controlling for case-mix, hospitals varied in LOT, LOS and hospital charges. CONCLUSION We found variation in hospital in treatment for NAS among major US children's hospitals. In analyses controlling for possible confounders, methadone as initial treatment was associated with reduced LOT and hospital stay.
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546
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Abstract
The incidence of neonatal abstinence syndrome (NAS) has increased dramatically during the past 15 years, likely due to an increase in antepartum maternal opiate use. Optimal care of these patients is still controversial because of the available published literature lacking sufficient sample size, placebo control, and comparative pharmacologic trials. Primary treatment for NAS consists of opioid replacement therapy with either morphine or methadone. Paregoric and tincture of opium have been abandoned because of relative safety concerns. Buprenorphine is emerging as a treatment option with promising initial experience. Adjunctive agents should be considered for infants failing treatment with opioid monotherapy. Traditionally, phenobarbital has been used as adjunctive therapy; however, results of clonidine as adjunctive therapy for NAS appear to be beneficial. Future directions for research in NAS should include validating a simplified scoring tool, conducting comparative studies, exploring home management options, and optimizing management through pharmacogenomics.
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Affiliation(s)
- Anita Siu
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, New Jersey ; Jersey Shore University Medical Center, Neptune, New Jersey
| | - Christine A Robinson
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, New Jersey ; Morristown Medical Center, Morristown, New Jersey
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547
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Brogly SB, Saia KA, Walley AY, Du HM, Sebastiani P. Prenatal buprenorphine versus methadone exposure and neonatal outcomes: systematic review and meta-analysis. Am J Epidemiol 2014; 180:673-86. [PMID: 25150272 DOI: 10.1093/aje/kwu190] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Increasing rates of maternal opioid use during pregnancy and neonatal withdrawal, termed neonatal abstinence syndrome (NAS), are public health concerns. Prenatal buprenorphine maintenance treatment (BMT) versus methadone maintenance treatment (MMT) may improve neonatal outcomes, but associations vary. To summarize evidence, we used a random-effects meta-analysis model and estimated summary measures of BMT versus MMT on several outcomes. Sensitivity analyses evaluated confounding, publication bias, and heterogeneity. Subjects were 515 neonates whose mothers received BMT and 855 neonates whose mothers received MMT and who were born from 1996 to 2012 and who were included in 12 studies. The unadjusted NAS treatment risk was lower (risk ratio=0.90, 95% confidence interval (CI): 0.81, 0.98) and mean length of hospital stay shorter (-7.23 days, 95% CI: -10.64, -3.83) in BMT-exposed versus MMT-exposed neonates. In treated neonates, NAS treatment duration was shorter (-8.46 days, 95% CI: -14.48, -2.44) and morphine dose lower (-3.60 mg, 95% CI: -7.26, 0.07) in those exposed to BMT. BMT-exposed neonates had higher mean gestational age and greater weight, length, and head circumference at birth. Fewer women treated with BMT used illicit opioids near delivery (risk ratio=0.44, 95% CI: 0.28, 0.70). Simulations suggested that confounding by indication could account for some of the observed differences. Prenatal BMT versus MMT may improve neonatal outcomes, but bias may contribute to this protective association. Further evidence is needed to guide treatment choices.
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548
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Bagley SM, Wachman EM, Holland E, Brogly SB. Review of the assessment and management of neonatal abstinence syndrome. Addict Sci Clin Pract 2014; 9:19. [PMID: 25199822 PMCID: PMC4166410 DOI: 10.1186/1940-0640-9-19] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 09/03/2014] [Indexed: 12/22/2022] Open
Abstract
Neonatal abstinence syndrome (NAS) secondary to in-utero opioid exposure is an increasing problem. Variability in assessment and treatment of NAS has been attributed to the lack of high-quality evidence to guide management of exposed neonates. This systematic review examines available evidence for NAS assessment tools, nonpharmacologic interventions, and pharmacologic management of opioid-exposed infants. There is limited data on the inter-observer reliability of NAS assessment tools due to lack of a standardized approach. In addition, most scales were developed prior to the prevalent use of prescribed prenatal concomitant medications, which can complicate NAS assessment. Nonpharmacologic interventions, particularly breastfeeding, may decrease NAS severity. Opioid medications such as morphine or methadone are recommended as first-line therapy, with phenobarbital or clonidine as second-line adjunctive therapy. Further research is needed to determine best practices for assessment, nonpharmacologic intervention, and pharmacologic management of infants with NAS in order to improve outcomes.
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Affiliation(s)
- Sarah Mary Bagley
- Section of General Internal Medicine, Boston University School of Medicine, 801 Mass Ave, 2nd Floor, Boston, MA 02118, USA.
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549
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Wiles JR, Isemann B, Ward LP, Vinks AA, Akinbi H. Current management of neonatal abstinence syndrome secondary to intrauterine opioid exposure. J Pediatr 2014; 165:440-6. [PMID: 24948346 PMCID: PMC4144410 DOI: 10.1016/j.jpeds.2014.05.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Revised: 04/01/2014] [Accepted: 05/01/2014] [Indexed: 11/25/2022]
Affiliation(s)
- Jason R Wiles
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Barbara Isemann
- Department of Pharmacy, University of Cincinnati Medical Center, Cincinnati, OH
| | - Laura P Ward
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Henry Akinbi
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
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550
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Wachman EM, Hayes MJ, Lester BM, Terrin N, Brown MS, Nielsen DA, Davis JM. Epigenetic variation in the mu-opioid receptor gene in infants with neonatal abstinence syndrome. J Pediatr 2014; 165:472-8. [PMID: 24996986 PMCID: PMC4145036 DOI: 10.1016/j.jpeds.2014.05.040] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 05/09/2014] [Accepted: 05/22/2014] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Neonatal abstinence syndrome (NAS) from in utero opioid exposure is highly variable with genetic factors appearing to play an important role. Epigenetic changes in cytosine:guanine (CpG) dinucleotide methylation can occur after drug exposure and may help to explain NAS variability. We correlated DNA methylation levels in the mu-opioid receptor (OPRM1) promoter in opioid-exposed infants with NAS outcomes. STUDY DESIGN DNA samples from cord blood or saliva were analyzed for 86 infants who were being treated for NAS according to institutional protocol. Methylation levels at 16 OPRM1 CpG sites were determined and correlated with NAS outcome measures, including need for treatment, treatment with ≥ 2 medications, and length of hospital stay. We adjusted for covariates and multiple genetic testing. RESULTS Sixty-five percent of infants required treatment for NAS, and 24% required ≥ 2 medications. Hypermethylation of the OPRM1 promoter was measured at the -10 CpG in treated vs nontreated infants (adjusted difference δ = 3.2% [95% CI, 0.3-6.0%], P = .03; nonsignificant after multiple testing correction). There was hypermethylation at the -14 (δ = 4.9% [95% CI, 1.8%-8.1%], P = .003), -10 (δ = 5.0% [95% CI, 2.3-7.7%], P = .0005), and +84 (δ = 3.5% [95% CI, 0.6-6.4], P = .02) CpG sites in infants requiring ≥ 2 medications, which remained significant for -14 and -10 after multiple testing correction. CONCLUSIONS Increased methylation within the OPRM1 promoter is associated with worse NAS outcomes, consistent with gene silencing.
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Affiliation(s)
| | - Marie J Hayes
- Psychology, Graduate School of Biomedical Sciences and Engineering, University of Maine, Orono, ME
| | - Barry M Lester
- Center for the Study of Children at Risk, Alpert Medical School of Brown University and Women and Infant's Hospital, Providence, RI
| | - Norma Terrin
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
| | - Mark S Brown
- Pediatrics, Eastern Maine Medical Center, Bangor, ME
| | - David A Nielsen
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX
| | - Jonathan M Davis
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA; Pediatrics, The Floating Hospital for Children at Tufts Medical Center, Boston, MA
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