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Bruce M, Compton AM, Maylott SE, Zhou AM, Raby KL, Crowell SE, Conradt E. The Combined Contributions of Newborn Stress and Parenting Stress on Toddler Language Development. J Pediatr 2024; 270:114006. [PMID: 38460711 PMCID: PMC11176021 DOI: 10.1016/j.jpeds.2024.114006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/07/2024] [Accepted: 03/01/2024] [Indexed: 03/11/2024]
Abstract
OBJECTIVE To examine the longitudinal associations between newborn neurobehavioral stress signs, maternal parenting stress, and several indices of toddler language development. STUDY DESIGN Participants include 202 mother-infant dyads (104 girls). We measured stress signs in neonates in the hospital at least 24 hours after birth using the Neonatal Intensive Care Unit Network Neurobehavioral Scale. At 7 months, parenting stress (competence, attachment, and role restriction) was assessed using the Parenting Stress Index. At 18 months, mothers completed the Communicative Development Inventories, which measured toddler gesturing, expressive vocabulary, and receptive vocabulary. Longitudinal path modeling was used to estimate associations between neonatal stress signs, parenting stress, and toddler language, and a model was generated for each language outcome. Child sex, birth weight, and family income were included as covariates. RESULTS Infants who exhibited greater neurobehavioral stress signs at birth produced significantly fewer social-communicative gestures at 18 months of age. Among infants whose mothers reported low (but not high) levels of parenting stress during the first postnatal year, newborn stress signs were negatively associated with 18-month-olds' receptive vocabulary size. Neither newborn stress signs nor parenting stress were significantly related to toddler expressive vocabulary size. CONCLUSIONS Our findings uncover a negative association between newborn stress signs and toddler gesturing. Furthermore, our results suggest that caregiver stress and neonatal stress signs interact to predict toddler receptive vocabulary. Taken together, these results demonstrate that some neonates who exhibit increased neurobehavioral stress signs may be at heightened risk for experiencing language difficulties. These children may benefit from additional support in infancy.
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Affiliation(s)
- Madeleine Bruce
- Department of Psychology, University of Utah, Salt Lake City, UT.
| | - Anna M Compton
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC
| | - Sarah E Maylott
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC
| | - Anna M Zhou
- Department of Psychology, University of Utah, Salt Lake City, UT
| | - K Lee Raby
- Department of Psychology, University of Utah, Salt Lake City, UT
| | | | - Elisabeth Conradt
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC
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Fong J, Lewis J, Lam M, Kesavan K. Developmental Outcomes after Opioid Exposure in the Fetus and Neonate. Neoreviews 2024; 25:e325-e337. [PMID: 38821910 DOI: 10.1542/neo.25-6-e325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/05/2023] [Accepted: 12/06/2023] [Indexed: 06/02/2024]
Abstract
The overall prevalence of opiate use has been increasing, currently affecting approximately 0.6% of the global population and resulting in a significant proportion of infants being born with prenatal opioid exposure. Animal and human models of prenatal opioid exposure demonstrate detrimental effects on brain anatomy as well as neurodevelopment. Less is known about the neurologic sequelae of postnatal opioid exposure in hospitalized infants. In this review, we summarize our current understanding of the impact of prenatal and postnatal opioid exposure on the brain and on neurodevelopment outcomes. We also identify resources and management strategies that may help mitigate neurodevelopmental delays and deficits associated with opioid exposure in this vulnerable population.
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Affiliation(s)
- Jeanette Fong
- Department of Pediatrics, University of California, Los Angeles, CA
| | - Juanita Lewis
- Department of Pediatrics, Olive View UCLA Medical Center, Sylmar, CA
| | - Melanie Lam
- Department of Pediatrics, University of California, Los Angeles, CA
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3
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Wouldes TA, Lester BM. Opioid, methamphetamine, and polysubstance use: perinatal outcomes for the mother and infant. Front Pediatr 2023; 11:1305508. [PMID: 38250592 PMCID: PMC10798256 DOI: 10.3389/fped.2023.1305508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 11/20/2023] [Indexed: 01/23/2024] Open
Abstract
The escalation in opioid pain relief (OPR) medications, heroin and fentanyl, has led to an increased use during pregnancy and a public health crisis. Methamphetamine use in women of childbearing age has now eclipsed the use of cocaine and other stimulants globally. Recent reports have shown increases in methamphetamine are selective to opioid use, particularly in rural regions in the US. This report compares the extent of our knowledge of the perinatal outcomes of OPRs, heroin, fentanyl, two long-acting substances used in the treatment of opioid use disorders (buprenorphine and methadone), and methamphetamine. The methodological limitations of the current research are examined, and two important initiatives that will address these limitations are reviewed. Current knowledge of the perinatal effects of short-acting opioids, OPRs, heroin, and fentanyl, is scarce. Most of what we know about the perinatal effects of opioids comes from research on the long-acting opioid agonist drugs used in the treatment of OUDs, methadone and buprenorphine. Both have better perinatal outcomes for the mother and newborn than heroin, but the uptake of these opioid substitution programs is poor (<50%). Current research on perinatal outcomes of methamphetamine is limited to retrospective epidemiological studies, chart reviews, one study from a treatment center in Hawaii, and the US and NZ cross-cultural infant Development, Environment And Lifestyle IDEAL studies. Characteristics of pregnant individuals in both opioid and MA studies were associated with poor maternal health, higher rates of mental illness, trauma, and poverty. Infant outcomes that differed between opioid and MA exposure included variations in neurobehavior at birth which could complicate the diagnosis and treatment of neonatal opioid withdrawal (NOWs). Given the complexity of OUDs in pregnant individuals and the increasing co-use of these opioids with MA, large studies are needed. These studies need to address the many confounders to perinatal outcomes and employ neurodevelopmental markers at birth that can help predict long-term neurodevelopmental outcomes. Two US initiatives that can provide critical research and treatment answers to this public health crisis are the US Environmental influences on Child Health Outcomes (ECHO) program and the Medication for Opioid Use Disorder During Pregnancy Network (MAT-LINK).
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Affiliation(s)
- Trecia A. Wouldes
- Department of Psychological Medicine, The University of Auckland, Auckland, New Zealand
| | - Barry M. Lester
- Center for the Study of Children at Risk, Warren Alpert Medical School, Brown University, Providence, RI, United States
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Camerota M, McGowan EC, Aschner J, Stroustrup A, Karagas MR, Conradt E, Crowell SE, Brennan PA, Carter BS, Check J, Dansereau LM, DellaGrotta SA, Everson TM, Helderman JB, Hofheimer JA, Kuiper JR, Loncar CM, Marsit CJ, Neal CR, O'Shea TM, Pastyrnak SL, Sheinkopf SJ, Smith LM, Zhang X, Lester BM. Prenatal and perinatal factors associated with neonatal neurobehavioral profiles in the ECHO Program. Pediatr Res 2023; 94:762-770. [PMID: 36841884 PMCID: PMC10440230 DOI: 10.1038/s41390-023-02540-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/23/2022] [Accepted: 02/06/2023] [Indexed: 02/27/2023]
Abstract
BACKGROUND Single-cohort studies have identified distinct neurobehavioral profiles that are associated with prenatal and neonatal factors based on the NICU Network Neurobehavioral Scale (NNNS). We examined socioeconomic, medical, and substance use variables as predictors of NNNS profiles in a multi-cohort study of preterm and term-born infants with different perinatal exposures. METHODS We studied 1112 infants with a neonatal NNNS exam from the Environmental influences on Child Health Outcomes (ECHO) consortium. We used latent profile analysis to characterize infant neurobehavioral profiles and generalized estimating equations to determine predictors of NNNS profiles. RESULTS Six distinct neonatal neurobehavioral profiles were identified, including two dysregulated profiles: a hypo-aroused profile (16%) characterized by lethargy, hypotonicity, and nonoptimal reflexes; and a hyper-aroused profile (6%) characterized by high arousal, excitability, and stress, with low regulation and poor movement quality. Infants in the hypo-aroused profile were more likely to be male, have younger mothers, and have mothers who were depressed prenatally. Infants in the hyper-aroused profile were more likely to be Hispanic/Latino and have mothers who were depressed or used tobacco prenatally. CONCLUSIONS We identified two dysregulated neurobehavioral profiles with distinct perinatal antecedents. Further understanding of their etiology could inform targeted interventions to promote positive developmental outcomes. IMPACT Prior research on predictors of neonatal neurobehavior have included single-cohort studies, which limits generalizability of findings. In a multi-cohort study of preterm and term-born infants, we found six distinct neonatal neurobehavioral profiles, with two profiles being identified as dysregulated. Hypo- and hyper-aroused neurobehavioral profiles had distinct perinatal antecedents. Understanding perinatal factors associated with dysregulated neurobehavior could help promote positive developmental outcomes.
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Affiliation(s)
- Marie Camerota
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA.
- Department of Pediatrics, Women and Infants Hospital, Providence, RI, USA.
| | - Elisabeth C McGowan
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, RI, USA
| | - Judy Aschner
- Departments of Pediatrics, Hackensack Meridian School of Medicine, Nutley, NJ, USA
- Albert Einstein College of Medicine, Bronx, NY, USA
| | - Annemarie Stroustrup
- Division of Neonatology, Cohen Children's Medical Center, Northwell Health, New Hyde Park, NY, USA
| | - Margaret R Karagas
- Department of Epidemiology, Geisel School of Medicine, Dartmouth College, Lebanon, NH, USA
| | - Elisabeth Conradt
- Department of Psychiatry, Duke University School of Medicine, Durham, NC, USA
| | - Sheila E Crowell
- Department of Psychology, University of Utah, Salt Lake City, UT, USA
| | | | - Brian S Carter
- Department of Pediatrics-Neonatology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Jennifer Check
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Lynne M Dansereau
- Department of Pediatrics, Women and Infants Hospital, Providence, RI, USA
| | | | - Todd M Everson
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jennifer B Helderman
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Julie A Hofheimer
- Department of Pediatrics, University of North Carolina and Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Jordan R Kuiper
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Cynthia M Loncar
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, RI, USA
| | - Carmen J Marsit
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Charles R Neal
- Department of Pediatrics, University of Hawaii John A. Burns School of Medicine, Honolulu, HI, USA
| | - Thomas Michael O'Shea
- Department of Pediatrics, University of North Carolina and Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Steven L Pastyrnak
- Department of Pediatrics, Spectrum Health-Helen DeVos Hospital, Grand Rapids, MI, USA
| | - Stephen J Sheinkopf
- Thompson Center for Autism and Neurodevelopment, University of Missouri, Columbia, MO, USA
| | - Lynne M Smith
- Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Xueying Zhang
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Barry M Lester
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
- Department of Pediatrics, Women and Infants Hospital, Providence, RI, USA
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, RI, USA
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Heller NA, Logan BA, Shrestha H, Morrison DG, Hayes MJ. Effect of Neonatal Abstinence Syndrome Treatment Status and Maternal Depressive Symptomatology on Maternal Reports of Infant Behaviors. J Pediatr Psychol 2023; 48:583-592. [PMID: 37159522 PMCID: PMC10321377 DOI: 10.1093/jpepsy/jsad023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 04/05/2023] [Accepted: 04/07/2023] [Indexed: 05/11/2023] Open
Abstract
OBJECTIVE The objective of this study is to investigate the effects of maternal perinatal depression symptoms and infant treatment status for neonatal abstinence syndrome (NAS) on maternal perceptions of infant regulatory behavior at 6 weeks of age. METHODS Mothers and their infants (N = 106; 53 dyads) were recruited from a rural, White cohort in Northeast Maine. Mothers in medication-assisted treatment (methadone) and their infants (n = 35 dyads) were divided based on the infant's NAS pharmacological treatment (n = 20, NAS+ group; n = 15, NAS- group) and compared with a demographically similar, nonexposed comparison group (n = 18 dyads; COMP group). At 6 weeks postpartum, mothers reported their depression symptoms Beck Depression Inventory-2nd Edition) and infant regulatory behaviors [Mother and Baby Scales (MABS)]. Infant neurobehavior was assessed during the same visit using the Neonatal Network Neurobehavioral Scale (NNNS). RESULTS Mothers in the NAS+ group showed significantly higher depression scores than the COMP group (p < .05) while the NAS- group did not. Across the sample, mothers with higher depression scores reported higher infant "unsettled-irregularity" MABS scores, regardless of group status. Agreement between maternal reports of infant regulatory behaviors and observer-assessed NNNS summary scares was poor in both the NAS+ and COMP groups. CONCLUSIONS Postpartum women in opioid recovery with infants requiring pharmacological intervention for NAS are more at risk for depression which may adversely influence their perceptions of their infants' regulatory profiles. Unique, targeted attachment interventions may be needed for this population.
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Affiliation(s)
| | - Beth A Logan
- Department of Psychiatry and Behavioral Sciences, Boston Children’s Hospital, USA
| | - Hira Shrestha
- Department of Medical Oncology, Dana-Farber Cancer Institute, USA
| | | | - Marie J Hayes
- Department of Psychology and Graduate School of Biomedical Sciences and Engineering, University of Maine, USA
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Camerota M, Davis JM, Dansereau LM, Oliveira EL, Padbury JF, Lester BM. Effects of Pharmacologic Treatment for Neonatal Abstinence Syndrome on DNA Methylation and Neurobehavior: A Prospective Cohort Study. J Pediatr 2022; 243:21-26. [PMID: 34971656 PMCID: PMC8960328 DOI: 10.1016/j.jpeds.2021.12.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 11/17/2021] [Accepted: 12/19/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine whether pharmacologic treatment for neonatal abstinence syndrome (NAS) is associated with changes in DNA methylation (DNAm) of the mu-opioid receptor gene (OPRM1) and improvements in neonatal neurobehavior. STUDY DESIGN Buccal swabs were collected from 37 neonates before and after morphine treatment for NAS. Genomic DNA was extracted, and DNAm was examined at 4 cytosine-phosphate-guanine (CpG) sites within the OPRM1 gene. Assessment with the NICU Network Neurobehavioral Scales (NNNS) was also performed before and after NAS treatment. Changes in DNAm (DNAmpost-tx - DNAmpre-tx) and NNNS summary scores (NNNSpost-tx - NNNSpre-tx) were then calculated. Path analysis was used to examine associations among pharmacologic treatment (length of treatment [LOT] and total dose of morphine), changes in DNAm, and changes in NNNS summary scores. RESULTS DNAm was significantly decreased from pretreatment to post-treatment at 1 of 4 CpG sites within the OPRM1 gene. Neonates also demonstrated decreased excitability, hypertonia, lethargy, signs of stress and abstinence, and increased quality of movement and regulation from pretreatment to post-treatment. Longer LOT and higher morphine dose were associated with greater decreases in DNAm; greater decreases in DNAm were associated with greater decreases in excitability and hypertonia on the NNNS. CONCLUSIONS Pharmacologic treatment of NAS is associated with decreased DNAm of the OPRM1 gene and improved neonatal neurobehavior. Epigenetic changes may play a role in these changes in neonatal neurobehavior.
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Affiliation(s)
- Marie Camerota
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI; Department of Pediatrics, Women and Infants Hospital, Providence, RI.
| | - Jonathan M. Davis
- Department of Pediatrics, Tufts Children’s Hospital and the Tufts Clinical and Translational Science Institute, Boston, MA, USA
| | - Lynne M. Dansereau
- Department of Pediatrics, Women and Infants Hospital, Providence, RI, USA
| | - Erica L. Oliveira
- Department of Pediatrics, Women and Infants Hospital, Providence, RI, USA
| | - James F. Padbury
- Department of Pediatrics, Women and Infants Hospital, Providence, RI, USA
| | - Barry M. Lester
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA,Department of Pediatrics, Women and Infants Hospital, Providence, RI, USA
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Etemadi-Aleagha A, Akhgari M. Psychotropic drug abuse in pregnancy and its impact on child neurodevelopment: A review. World J Clin Pediatr 2022; 11:1-13. [PMID: 35096542 PMCID: PMC8771314 DOI: 10.5409/wjcp.v11.i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/21/2021] [Accepted: 11/29/2021] [Indexed: 02/06/2023] Open
Abstract
Substance abuse by women of child-bearing age and fetal in utero drug exposure has increased in the number of infants born with health issues. Prenatal exposure to psychoactive substances can lead to neurological and neurodevelopmental deficits later in life. Useful data concerning the effects of psychoactive drugs on fetal neurodevelopmental status are sparse. Understanding the neurodevelopmental consequences of prenatally drug-exposed children has become a pressing global concern. The aim of this review is to gather current evidence and information on neurodevelopmental outcomes of in utero drug exposure. A literature search was performed on the PubMed, Scopus, and Google Scholar databases using the terms “psychotropic drugs”, “neurodevelopmental consequences”, “prenatal drug exposure”, and “pregnancy”. Available studies on in utero drug exposure were reviewed and found to support the idea that some degree of health issues are present in fetuses and children. Different psychoactive substances have profound neurodevelopmental consequences, such as structural brain changes, poor attention span, Down syndrome, attention deficit hyperactivity disorder, autism spectrum disorder, imbalances in neurotransmitter levels, and many structural deficits. The pervasive use of psychoactive drugs in women of child-bearing age is an important health concern. Further scientific efforts are needed to investigate the effect of prenatal exposure to psychoactive drugs on children.
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Affiliation(s)
- Afshar Etemadi-Aleagha
- Department of Anesthesiology and Intensive Care, Tehran University of Medical Sciences, Tehran 1145765111, Iran
| | - Maryam Akhgari
- Legal Medicine Research Center, Legal Medicine Organization, Tehran 1114795113, Iran
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Reconceptualizing non-pharmacologic approaches to Neonatal Abstinence Syndrome (NAS) and Neonatal Opioid Withdrawal Syndrome (NOWS): A theoretical and evidence-based approach. Part II: The clinical application of nonpharmacologic care for NAS/NOWS. Neurotoxicol Teratol 2021; 88:107032. [PMID: 34600100 DOI: 10.1016/j.ntt.2021.107032] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 09/22/2021] [Accepted: 09/24/2021] [Indexed: 11/20/2022]
Abstract
There has been increasing emphasis on the importance of the development of self-regulatory capacities of the individual as the cornerstone of development. The caregivers' abilities to manage their own attention, emotions, physiology and behaviors influence the development of the child's self-regulatory and interactive capacities, and thereby their overall development. Newborns prenatally exposed to psychoactive substances and/or to other prenatal stressors such as maternal poor nutrition, increased maternal stress, trauma, difficult and/or impoverished environments, in tandem with genetic predispositions, can result in alterations to their neurodevelopment that predispose them to self-regulatory problems that can be expressed at any stage of life. The care of infants with Neonatal Abstinence Syndrome (NAS)/Neonatal Opioid Withdrawal Syndrome (NOWS) and their mother/caregiver is a window of opportunity to assess the regulatory and co-regulatory capacities of both, and to provide holistic interventions with the goal of empowering the mother/caregiver in their own self-knowledge/self-regulation capacities and their crucial role in promoting the healthy development of their children. Non-pharmacologic care for the infant with NAS/NOWS is the first line of treatment and of paramount importance. Yet, current approaches are based on a limited scope of infant functioning, and the scoring systems in current use do not result in individualized and specific non-pharmacologic care of the infant, which can result in excessive or insufficient medication and a lack of caregiver appreciation for the infant's strengths, difficulties and early development. The interventions described here are based on the infant's signs of dysregulation in four neurobehavioral subsystems that can be dysregulated by NAS/NOWS, the infant's adaptive or maladaptive responses to return to a regulated functioning, and the co-regulatory behaviors of the infant and the mother/caregiver. In Part I of this two-part series on re-conceptualizing non-pharmacologic care for NAS/NOWS we laid the foundation for a new treatment approach, one grounded in developmental theory and evidence-based observations of infant and interpersonal neurobiology. Here, in Part II, we outline actionable, individually tailored evaluations and approaches to non-pharmacologic NAS/NOWS treatment based on strategies to support the regulatory capacities and development of 4 key domains: 1) autonomic; 2) motor/tone; 3) sleep/awake state control; and 4) sensory modulation subsystems.
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Casavant SG, Meegan T, Fleming M, Hussain N, Gork S, Cong X. Integrated Review of the Assessment of Newborns With Neonatal Abstinence Syndrome. J Obstet Gynecol Neonatal Nurs 2021; 50:539-548. [PMID: 34116058 DOI: 10.1016/j.jogn.2021.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To critically review and summarize current knowledge regarding the assessment of newborns with neonatal abstinence syndrome (NAS). DATA SOURCES We searched the following databases for articles on the assessment of newborns with NAS that were published in English between January 2014 and June 2020: PubMed, CINAHL, and PsycINFO. Keywords and Medical Subject Heading terms used to identify relevant research articles included neonatal abstinence syndrome; Finnegan Scale; eat, sleep, console; epigenetics; genetics; pharmacokinetics; and measurement. We independently reviewed articles for inclusion. STUDY SELECTION We retrieved 435 articles through database searches and 17 through manual reference searches; 31 articles are included in the final review. Excluded articles were duplicates, not relevant to NAS, qualitative studies, and/or of low quality. DATA EXTRACTION We used the methodology of Whittemore and Knafl to guide this integrative review. We extracted and organized data under the following headings: author, year and country, purpose, study design, participants, measurement, biomarker (if applicable), results, limitations, recommendations, and intervention. DATA SYNTHESIS The Finnegan Neonatal Abstinence Scale is the most widely used instrument to measure symptoms of NAS in newborns, although it is very subjective. Recently, there has been a transition from the Finnegan Neonatal Abstinence Scale to the eat, sleep, console method, which consists of structured assessment and intervention and has been shown to decrease length of hospital stay and total opioid treatment dose. Researchers examined biomarkers of NAS, including genetic markers and autonomic nervous system responses, on the variation in incidence and differential severity of NAS. In the included articles, women with opioid use disorder who were treated with naltrexone during pregnancy gave birth to newborns without NAS diagnoses. However, most women who were treated with buprenorphine gave birth to newborns with NAS diagnoses. CONCLUSION NAS negatively affects newborns in a multitude of ways, and the objective assessment and measurement of the newborn's response to withdrawal remains understudied and needs further investigation.
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Heller NA, Shrestha H, Morrison DG, Daigle KM, Logan BA, Paul JA, Brown MS, Hayes MJ. Neonatal sleep development and early learning in infants with prenatal opioid exposure. ADVANCES IN CHILD DEVELOPMENT AND BEHAVIOR 2021; 60:199-228. [PMID: 33641794 DOI: 10.1016/bs.acdb.2020.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The aim of this chapter is to examine the role of sleep and cognition in the context of the cumulative risk model examining samples of at-risk infants and maternal-infant dyads. The cumulative risk model posits that non-optimal developmental outcomes are the result of multiple factors in a child's life including, but not limited to, prenatal teratogenic exposures, premature birth, family socioeconomic status, parenting style and cognitions as well as the focus of this volume, sleep. We highlight poor neonatal sleep as both an outcome of perinatal risk as well as a risk factor to developing attentional and cognitive capabilities during early childhood. Outcomes associated with and contributing to poor sleep and cognition during infancy are examined in relation to other known risks in our clinical population. Implications of this research and recommendations for interventions for this population are provided.
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Affiliation(s)
- Nicole A Heller
- Department of Psychology, Siena College, Loudonville, NY, United States
| | - Hira Shrestha
- Department of Pediatrics, Boston Medical Center, Boston, MA, United States
| | - Deborah G Morrison
- Department of Psychiatry, University of Florida, Gainesville, FL, United States
| | - Katrina M Daigle
- Department of Psychology, Suffolk University, Boston, MA, United States
| | - Beth A Logan
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States
| | - Jonathan A Paul
- Graduate School of Biomedical Sciences and Engineering, University of Maine, Orono, ME, United States
| | - Mark S Brown
- Department of Pediatrics, Northern Light Eastern Maine Medical Center, Bangor, ME, United States
| | - Marie J Hayes
- Department of Psychology and Graduate School of Biomedical Sciences and Engineering, University of Maine, Orono, ME, United States.
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McPhail BT, Emoto C, Butler D, Fukuda T, Akinbi H, Vinks AA. Opioid Treatment for Neonatal Opioid Withdrawal Syndrome: Current Challenges and Future Approaches. J Clin Pharmacol 2021; 61:857-870. [PMID: 33382111 DOI: 10.1002/jcph.1811] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 12/26/2020] [Indexed: 02/06/2023]
Abstract
Chronic intrauterine exposure to psychoactive drugs often results in neonatal opioid withdrawal syndrome (NOWS). When nonpharmacologic measures are insufficient in controlling NOWS, morphine, methadone, and buprenorphine are first-line medications commonly used to treat infants with NOWS because of in utero exposure to opioids. Research suggests that buprenorphine may be the leading drug therapy used to treat NOWS when compared with morphine and methadone. Currently, there are no consensus or standardized treatment guidelines for medications prescribed for NOWS. Opioids used to treat NOWS exhibit large interpatient variability in pharmacokinetics (PK) and pharmacodynamic (PD) response in neonates. Organ systems undergo rapid maturation after birth that may alter drug disposition and exposure for any given dose during development. Data regarding the PK and PD of opioids in neonates are sparse. Pharmacometric methods such as physiologically based pharmacokinetic and population pharmacokinetic modeling can be used to explore factors predictive of some of the variability associated with the PK/PD of opioids in newborns. This review discusses the utility of pharmacometric techniques for enhancing precision dosing in infants requiring opioid treatment for NOWS. Applying these approaches may contribute to optimizing the outcome by reducing cumulative drug exposure, mitigating adverse drug effects, and reducing the burden of NOWS in neonates.
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Affiliation(s)
- Brooks T McPhail
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Biomedical Sciences, University of South Carolina School of Medicine Greenville, Greenville, South Carolina, USA
| | - Chie Emoto
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Dawn Butler
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Tsuyoshi Fukuda
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Henry Akinbi
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Perinatal Institute, Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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12
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Flannery T, Davis JM, Czynski AJ, Dansereau LM, Oliveira EL, Camardo SA, Lester BM. Neonatal Abstinence Syndrome Severity Index Predicts 18-Month Neurodevelopmental Outcome in Neonates Randomized to Morphine or Methadone. J Pediatr 2020; 227:101-107.e1. [PMID: 32805259 PMCID: PMC7731918 DOI: 10.1016/j.jpeds.2020.08.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/09/2020] [Accepted: 08/12/2020] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To develop an index to determine which opioid-exposed neonates have the most severe neonatal abstinence syndrome (NAS). STUDY DESIGN Full-term neonates with NAS (n = 116) from mothers maintained on methadone or buprenorphine were enrolled from 8 sites into a randomized clinical trial of morphine vs methadone. Ninety-nine (85%) were evaluated at hospital discharge using the NICU Network Neurobehavioral Scale (NNNS). At 18 months, 83 of 99 (83.8%) were evaluated with the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III), and 77 of 99 (77.7%) were evaluated with the Child Behavior Checklist (CBCL). RESULTS Cluster analysis was used to define high (n = 21) and low (n = 77) NAS severity. Compared with infants in the low NAS severity cluster, infants in the high NAS severity cluster had a longer length of stay (P < .001), longer length of stay due to NAS (P < .001), longer duration of treatment due to NAS (P < .001), and higher total dose of the study drug (P < .001) and were more likely to have received phenobarbital (P < .001), to have been treated with morphine (P = .020), and to have an atypical NNNS profile (P = .005). The 2 groups did not differ in terms of maximum Finnegan score. At 18 months, in unadjusted analyses, compared with the high-severity cluster, the low-severity cluster had higher scores on the Bayley-III Cognitive (P = .013), Language (P < .001), and Motor (P = .041) composites and less total behavior problems on the CBCL (P = .028). In adjusted analyses, the difference in the Bayley-III Language composite remained (P = .013). CONCLUSIONS Presumptive measures of NAS severity can be aggregated to develop an index that predicts developmental outcomes at age 18 months.
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Affiliation(s)
- Tess Flannery
- Brown Center for the Study of Children at Risk and Women and Infants Hospital, Providence, RI
| | - Jonathan M Davis
- Department of Pediatrics, The Floating Hospital for Children at Tufts Medical Center, Boston, MA; Tufts Clinical and Translational Science Institute, Boston, MA; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
| | - Adam J Czynski
- Department of Pediatrics, Warren Alpert Medical School of Brown University and Women and Infants Hospital, Providence, RI
| | - Lynne M Dansereau
- Brown Center for the Study of Children at Risk and Women and Infants Hospital, Providence, RI
| | - Erica L Oliveira
- Brown Center for the Study of Children at Risk and Women and Infants Hospital, Providence, RI
| | - Samantha A Camardo
- Brown Center for the Study of Children at Risk and Women and Infants Hospital, Providence, RI
| | - Barry M Lester
- Brown Center for the Study of Children at Risk and Women and Infants Hospital, Providence, RI; Department of Pediatrics, Warren Alpert Medical School of Brown University and Women and Infants Hospital, Providence, RI; Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI.
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13
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Wouldes TA, Woodward LJ. Neurobehavior of newborn infants exposed prenatally to methadone and identification of a neurobehavioral profile linked to poorer neurodevelopmental outcomes at age 24 months. PLoS One 2020; 15:e0240905. [PMID: 33064777 PMCID: PMC7567379 DOI: 10.1371/journal.pone.0240905] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 10/05/2020] [Indexed: 11/25/2022] Open
Abstract
The abuse of prescription opioids and heroin by women of childbearing age over the past decade has resulted in a five-fold increase in the number of infants born opioid-dependent. Daily opioid substitution treatment with methadone is associated with less maternal illicit opioid use and improved antenatal care. However, research on the neurobehavioral effects of daily prenatal exposure to methadone on the infant is limited. Using the NICU Network Neurobehavioral Scale (NNNS), we compared the neurobehavior at birth of 86 infants born to opioid-dependent mothers receiving methadone treatment (MMT) with 103 infants unexposed to methadone. Generalized linear models, adjusted for covariates, showed methadone exposed infants had significantly poorer attention, regulation, and quality of movement. They were also significantly more excitable, more easily aroused, exhibited more non-optimal reflexes, hypertonicity, and total signs of stress abstinence. Maternal MMT was also associated with more indices of neonatal abstinence, including: CNS, visual, genitourinary (GI), and state. Latent profile analysis of the NNNS summary scores revealed four distinct neurobehavioral profiles with infants characterized by the most disturbed neurobehavior at birth having the poorest clinical outcomes at birth, and poorer cognitive and motor development at 24 months of age.
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Affiliation(s)
- Trecia A. Wouldes
- Department of Psychological Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Lianne J. Woodward
- School of Health Sciences, University of Canterbury, Christchurch, New Zealand
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14
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Bauer CR, Langer J, Lambert-Brown B, Shankaran S, Bada HS, Lester B, Lagasse LL, Whitaker T, Hammond J. Association of prenatal opiate exposure with youth outcomes assessed from infancy through adolescence. J Perinatol 2020; 40:1056-1065. [PMID: 32444681 DOI: 10.1038/s41372-020-0692-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 04/23/2020] [Accepted: 05/11/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE This study examined acute findings and long-term outcome trajectories between birth and adolescence in children with prenatal opiate exposure. STUDY DESIGN Ninety children (45 opiate-exposed, 45 non-exposed) completed assessments between 1 month and 15 years of age. Outcome variables (medical, anthropomorphic, developmental, and behavioral) were analyzed at individual time points and using longitudinal statistical modeling. RESULTS Opiate-exposed infants displayed transient neurologic findings, but no substantial signs or symptoms long term. There were no group differences in growth, cognitive functioning, or behavior at individual time periods; however, the trajectories of outcomes using longitudinal analyses adjusting for variables known to impact outcome demonstrated increased deficits among opiate-exposed children over time with regards to weight, head circumference, cognitive functioning, and behavior. CONCLUSIONS Findings support concerns that maternal opiate use during pregnancy may negatively impact a child's developmental trajectory, which in turn may impose concerns to society (e.g., increased need for social, medical, and/or educational services).
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Affiliation(s)
- Charles R Bauer
- Department of Pediatrics, Miller School of Medicine, University of Miami, Miami, FL, 33136, USA.
| | - John Langer
- Statistics and Epidemiology, RTI International, Research Triangle Park, NC, 27709, USA
| | - Brittany Lambert-Brown
- Department of Pediatrics, Miller School of Medicine, University of Miami, Miami, FL, 33136, USA
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI, 48201, USA
| | - Henrietta S Bada
- Department of Pediatrics, University of Kentucky Hospital, Lexington, KY, 40506, USA
| | - Barry Lester
- Department of Pediatrics Brown Center for the Study of Children at Risk, Warren Alpert Medical School of Brown University, Women and Infants Hospital of Rhode Island, Providence, RI, 02903, USA
| | - Lynn L Lagasse
- Department of Pediatrics Brown Center for the Study of Children at Risk, Warren Alpert Medical School of Brown University, Women and Infants Hospital of Rhode Island, Providence, RI, 02903, USA
| | - Toni Whitaker
- Boling Center for Developmental Disabilities, University of Tennessee Health Science Center, Memphis, TN, 38105, USA
| | - Jane Hammond
- Statistics and Epidemiology, RTI International, Research Triangle Park, NC, 27709, USA
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15
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Daigle KM, Heller NA, Sulinski EJ, Shim J, Lindblad W, Brown MS, Gosse JA, Hayes MJ. Maternal responsivity and oxytocin in opioid-dependent mothers. Dev Psychobiol 2020; 62:21-35. [PMID: 31401811 PMCID: PMC10465066 DOI: 10.1002/dev.21897] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 05/22/2019] [Accepted: 06/24/2019] [Indexed: 12/14/2022]
Abstract
Although prenatal opioid exposure and postnatal withdrawal (neonatal abstinence syndrome) are associated with infant neurobehavioral deficits, little is known about the impact of continued maternal opioid treatment in the postnatal period on maternal responsivity and relationship to mother's oxytocin release during dyadic interactions in the Still Face paradigm. Mother and infant dyads (N = 14) were recruited and comprised of mothers on opioid replacement throughout pregnancy and postpartum (opioid-exposed group, n = 7) and a demographically controlled, non-exposed group (n = 7). Salivary oxytocin was collected following 10 min of infant separation before and immediately after a 6-min Still Face paradigm. Oxytocin measures correlated strongly with sensitive and prosocial maternal behaviors in response to infant initiation. Opioid-exposed compared to non-exposed mothers had significantly lower pre-test to post-test rise in salivary oxytocin concentration level as well as fewer sensitive behaviors during the reunion condition of the Still Face paradigm. Maternal opioid dependence during early infancy may impair maternal responsivity and sensitivity through suppression of the oxytocin reflex to infant stimulation.
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Affiliation(s)
| | - Nicole A Heller
- Department of Psychology, Siena College, Loudonville, New York
| | | | - Juyoung Shim
- Department of Molecular and Biomedical Sciences, University of Maine, Orono, Maine
| | | | - Mark S Brown
- Department of Pediatrics, Northern Light Eastern Maine Medical Center, Bangor, Maine
| | - Julie A Gosse
- Department of Molecular and Biomedical Sciences, University of Maine, Orono, Maine
| | - Marie J Hayes
- Department of Psychology, University of Maine, Orono, Maine
- Graduate School of Biomedical Sciences and Engineering, University of Maine, Orono, Maine
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16
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Benninger KL, Borghese T, Kovalcik JB, Moore-Clingenpeel M, Isler C, Bonachea EM, Stark AR, Patrick SW, Maitre NL. Prenatal Exposures Are Associated With Worse Neurodevelopmental Outcomes in Infants With Neonatal Opioid Withdrawal Syndrome. Front Pediatr 2020; 8:462. [PMID: 32974241 PMCID: PMC7481438 DOI: 10.3389/fped.2020.00462] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/01/2020] [Indexed: 01/12/2023] Open
Abstract
Aim: To define a developmental trajectory in infants with neonatal opioid withdrawal syndrome (NOWS) and determine whether the impacted developmental domain varies with the type of antenatal exposure. Methods: We performed a retrospective cohort study of infants treated pharmacologically for NOWS and assessed using a standardized schedule for follow-up visits. We compared outcomes of the study population to published norms using one-sample t-tests. Multivariable models examined associations with exposures in addition to opioids. Results: In our cohort of 285 infants with 9-12-months testing, 164 (55.7%) were seen at 3-4 months, and 125 (44%), at 15-18 months. The majority (58%) had intrauterine drug exposures in addition to opioids. Neurodevelopmental scores of infants with NOWS at 3-4 and 9-12 months were not different from published norms. Cognitive and language scores at 15-18 months were worse than published norms. Male sex, older maternal age, and additional barbiturate or alcohol exposure were associated with worse outcomes. Conclusion: Infants with pharmacologically treated NOWS had development similar to unexposed infants during the 1st year but worse cognitive and language scores during the 2nd year. These data support the need for a prospective follow-up of large cohorts of infants with NOWS, with systematic assessments and an evaluation of contributing factors.
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Affiliation(s)
- Kristen L Benninger
- Department of Pediatrics and Neonatology, Nationwide Children's Hospital, Columbus, OH, United States.,Center for Perinatal Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, United States
| | - Teresa Borghese
- Department of Pediatrics and Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Jason B Kovalcik
- Department of Pediatrics and Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Melissa Moore-Clingenpeel
- Biostatistics Core, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, United States
| | - Cherie Isler
- Department of Pediatrics and Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Elizabeth M Bonachea
- Department of Pediatrics and Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Ann R Stark
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Stephen W Patrick
- Departments of Pediatrics and Health Policy, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Nathalie L Maitre
- Department of Pediatrics and Neonatology, Nationwide Children's Hospital, Columbus, OH, United States.,Center for Perinatal Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, United States.,Department of Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, TN, United States
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17
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Konijnenberg C, Melinder A. Salivary cortisol levels relate to cognitive performance in children prenatally exposed to methadone or buprenorphine. Dev Psychobiol 2019; 62:409-418. [PMID: 31564069 DOI: 10.1002/dev.21921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 06/24/2019] [Accepted: 08/25/2019] [Indexed: 11/11/2022]
Abstract
Opioid maintenance therapy (OMT) is generally recommended for pregnant opioid-dependent women. However, much is still unknown about the potential long-term effects of prenatal methadone and buprenorphine exposure. This study explored the long-term effects of prenatal methadone and buprenorphine exposure in a cohort (n = 41) of children, aged 9-11 years, using the Wechsler Abbreviated Scale of Intelligence (WASI) to measure cognitive development and salivary cortisol samples to measure HPA-axis activity. Prenatally exposed children scored significantly lower on all four subtests of WASI (vocabulary, similarities, block design, and matrix reasoning), compared to a comparison group (all p < .05). No group differences were found for salivary cortisol levels or cortisol reactivity levels (all p > .05). Cortisol levels significantly predicted matrix reasoning scores for the OMT group, β = -65.58, t(20) = 15.70, p = .02. Findings suggest that prenatal exposure to methadone or buprenorphine does not have long-term effects on children's HPA-axis functioning. However, since children of women in OMT scored significantly lower on tasks of cognitive function, careful follow-up throughout the school years and across adolescence is recommended.
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Affiliation(s)
- Carolien Konijnenberg
- Department of Psychology, Inland Norway University of Applied Sciences, Lillehammer, Norway.,Cognitive Developmental Research Unit, Department of Psychology, University of Oslo, Oslo, Norway
| | - Annika Melinder
- Cognitive Developmental Research Unit, Department of Psychology, University of Oslo, Oslo, Norway.,Oslo University Hospital, Child- and Adolescents Mental Health, Oslo, Norway
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18
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Conradt E, Flannery T, Aschner JL, Annett RD, Croen LA, Duarte CS, Friedman AM, Guille C, Hedderson MM, Hofheimer JA, Jones MR, Ladd-Acosta C, McGrath M, Moreland A, Neiderhiser JM, Nguyen RH, Posner J, Ross JL, Savitz DA, Ondersma SJ, Lester BM. Prenatal Opioid Exposure: Neurodevelopmental Consequences and Future Research Priorities. Pediatrics 2019; 144:peds.2019-0128. [PMID: 31462446 PMCID: PMC6759228 DOI: 10.1542/peds.2019-0128] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/22/2019] [Indexed: 01/14/2023] Open
Abstract
Neonatal opioid withdrawal syndrome (NOWS) has risen in prevalence from 1.2 per 1000 births in 2000 to 5.8 per 1000 births in 2012. Symptoms in neonates may include high-pitched cry, tremors, feeding difficulty, hypertonia, watery stools, and breathing problems. However, little is known about the neurodevelopmental consequences of prenatal opioid exposure in infancy, early childhood, and middle childhood. Even less is known about the cognitive, behavioral, and academic outcomes of children who develop NOWS. We review the state of the literature on the neurodevelopmental consequences of prenatal opioid exposure with a particular focus on studies in which NOWS outcomes were examined. Aiming to reduce the incidence of prenatal opioid exposure in the near future, we highlight the need for large studies with prospectively recruited participants and longitudinal designs, taking into account confounding factors such as socioeconomic status, institutional variations in care, and maternal use of other substances, to independently assess the full impact of NOWS. As a more immediate solution, we provide an agenda for future research that leverages the National Institutes of Health Environmental Influences on Child Health Outcomes program to address many of the serious methodologic gaps in the literature, and we answer key questions regarding the short- and long-term neurodevelopmental health of children with prenatal opioid exposure.
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Affiliation(s)
- Elisabeth Conradt
- Departments of Psychology, Pediatrics, and Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah;
| | | | - Judy L. Aschner
- Department of Pediatrics, Albert Einstein College of Medicine, New York, New York;,Department of Pediatrics, Hackensack Meridian School of Medicine, Seton Hall University, Nutley, New Jersey
| | - Robert D. Annett
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi
| | - Lisa A. Croen
- Division of Research, Kaiser Permanente, Oakland, California
| | - Cristiane S. Duarte
- New York State Psychiatric Institute,,Department of Psychiatry, Columbia University, New York, New York
| | - Alexander M. Friedman
- Division of Maternal-Fetal Medicine, Columbia University Irving Medical Center, New York, New York
| | | | | | - Julie A. Hofheimer
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Christine Ladd-Acosta
- Department of Epidemiology and,Wendy Klag Center for Autism and Developmental Disabilities, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | | | - Angela Moreland
- National Crime Victims Research and Treatment Center, Medical University of South Carolina, Columbia, South Carolina
| | - Jenae M. Neiderhiser
- Department of Psychology, The Pennsylvania State University, University Park, Pennsylvania
| | - Ruby H.N. Nguyen
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Jonathan Posner
- Department of Psychiatry, Columbia University, New York, New York
| | - Judith L. Ross
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware; and
| | | | - Steven J. Ondersma
- Merrill Palmer Skillman Institute and Department of Psychiatry and Behavioral Neurosciences, Wayne State University, Detroit, Michigan
| | - Barry M. Lester
- Brown Center for the Study of Children at Risk and Departments of Psychiatry and Human Behavior and Pediatrics, Alpert Medical School, Brown University, Providence, Rhode Island;,Women and Infants Hospital in Rhode Island, Providence, Rhode Island
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19
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Wachman EM, Minear S, Hirashima M, Hansbury A, Hutton E, Shrestha H, Combs G, Barry K, Slater C, Stickney D, Walley AY. Standard Fixed-Schedule Methadone Taper Versus Symptom-Triggered Methadone Approach for Treatment of Neonatal Opioid Withdrawal Syndrome. Hosp Pediatr 2019; 9:576-584. [PMID: 31270130 DOI: 10.1542/hpeds.2018-0165] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVES We compared hospitalization outcomes in infants with neonatal opioid withdrawal syndrome (NOWS) treated with a novel symptom-triggered methadone approach (STMA) versus a fixed-schedule methadone taper (FSMT). METHODS This was a single-center quality-improvement study of infants pharmacologically treated for NOWS. Outcomes were compared over time by using statistical process control charts and between the baseline FSMT (July 2016-November 2017) and intervention STMA (December 2017-May 2018) groups, including median hospital length of stay (LOS), methadone treatment days, total milligrams of methadone, and need for adjunctive agents. RESULTS There were 48 infants in the FSMT group and 28 in the STMA group. Infants treated with STMA had a median LOS of 10.5 days (interquartile range [IQR] 10.5) versus 17.0 days (IQR 3.9; P = .003) in the FSMT group, with a 9.2-day difference in methadone treatment days (2.5 [IQR 9.0] vs 11.7 [IQR 4.0]; P = .0001), meeting criteria for statistical process control special cause variation. The average number of symptom-triggered doses was 2.1 (SD 1.0). Six infants in the STMA group were converted to FSMT after failing a trial of STMA. Infants successfully treated with the STMA (N = 22) had a median LOS of 10.0 days (IQR 4.0) compared with 17.0 (IQR 3.9) in the baseline FSMT group (P < .0001). CONCLUSIONS STMA was associated with a significant reduction in median LOS and amount of methadone treatment. A symptom-triggered approach to NOWS may reduce LOS and medication exposure.
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Affiliation(s)
| | | | | | | | - Elizabeth Hutton
- Departments of Pediatrics and
- Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts; and
| | | | | | | | | | | | - Alexander Y Walley
- Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts; and
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20
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McCarty DB, Peat JR, O'Donnell S, Graham E, Malcolm WF. "Choose Physical Therapy" for Neonatal Abstinence Syndrome: Clinical Management for Infants Affected by the Opioid Crisis. Phys Ther 2019; 99:771-785. [PMID: 31155664 DOI: 10.1093/ptj/pzz039] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 02/13/2019] [Indexed: 11/14/2022]
Abstract
In response to the opioid crisis, the American Physical Therapy Association has strongly advocated for physical therapy as a safe alternative to pharmacological pain management through the "#ChoosePT" campaign and the dedication of a PTJ special issue to the nonpharmacological management of pain. Physical therapists not only play an important role in the rehabilitation of the nearly 2 million adolescents and adults addicted to prescription opioids but also provide care to infants born to mothers with various drug addictions. This Perspective article explores the incidence, pathophysiology, and risk factors for neonatal abstinence syndrome and describes the clinical presentations of withdrawal and neurotoxicity in infants. Discipline-specific recommendations for the physical therapist examination and plan of care, including pharmacological management considerations, are outlined. Nonpharmacological management, including supportive care, feeding, parent education, social aspects of care, and follow-up services, are discussed from a physical therapy perspective. Finally, this article reviews developmental outcomes in infants with neonatal abstinence syndrome and reflects on challenges and future directions of research in this area.
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Affiliation(s)
- Dana B McCarty
- Division of Physical Therapy, The University of North Carolina at Chapel Hill, 3044 Bondurant Hall, CB#7135, Chapel Hill, NC 27599 (USA)
| | - Jennifer R Peat
- Department of Physical Therapy, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Shannon O'Donnell
- Department of Physical and Occupational Therapy, Duke University Medical Center, Durham, North Carolina
| | - Elisabeth Graham
- Department of Physical and Occupational Therapy, Duke University Medical Center
| | - William F Malcolm
- Department of Pediatrics/Neonatology, Duke University Medical Center
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21
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Rose-Jacobs R, Trevino-Talbot M, Lloyd-Travaglini C, Cabral HJ, Vibbert M, Saia K, Wachman EM. Could prenatal food insecurity influence neonatal abstinence syndrome severity? Addiction 2019; 114:337-343. [PMID: 30422365 DOI: 10.1111/add.14458] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 05/03/2018] [Accepted: 09/25/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS In general populations, prenatal food insecurity negatively affects maternal and infant health. Our aim was to estimate and test the association between prenatal food insecurity and neonatal abstinence syndrome (NAS) severity. DESIGN/SETTING Single-site prospective cohort design. Women receiving opioid agonist treatment with methadone or buprenorphine were interviewed (including demographics and food insecurity) during the third trimester at the combined obstetric/opioid use disorder treatment clinic at Boston Medical Center (BMC) in Boston, MA, USA, a large urban safety-net hospital. During postnatal hospitalization, infants were assessed and treated per hospital NAS protocol. Maternal clinic and infant hospitalization data were abstracted from medical records. PARTICIPANTS Women (n = 75; aged ≥ 18 years; fluent English; singleton pregnancy; intending to deliver at BMC and maintain parental custody) receiving care in the specialized clinic were study eligible (2013-15). Women who delivered infants < 36 weeks gestational age or required prolonged newborn intensive care unit stay were excluded from analyses. PRIMARY MEASUREMENTS Predictors: validated two-question Hunger Vital Sign™ food insecurity screener; outcomes: extent of NAS pharmacological treatment and length of hospital stay (LOS) for NAS. FINDINGS Of the mother-infant dyads, 61 (81%) infants were treated pharmacologically for NAS. Mean hospital LOS was 19.9 (standard deviation = 9.4) days. Maternal food insecurity (n = 43, 57.3%) was associated with infant NAS pharmacological treatment in logistic regression analyses individually adjusted for prenatal: maternal depression [adjusted odds ratios (aOR) = 3.69 (95% confidence intervals (CI) = 1.02-13.43, P = 0.05)] and methadone agonist treatment [aOR = 4.17 (95% CI = 1.05-16.50, P = 0.04)]. Associations of food insecurity and LOS were inconclusive regardless of covariate control (P > 0.05). CONCLUSION Among women receiving opioid agonist treatment, prenatal food insecurity appears to be associated with increased risk for neonatal abstinence syndrome pharmacological treatment.
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Affiliation(s)
- Ruth Rose-Jacobs
- Pediatrics, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | | | - Christine Lloyd-Travaglini
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, USA
| | - Howard J Cabral
- Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Martha Vibbert
- Pediatrics, Boston University School of Medicine and Boston Medical Center, Mattapan, MA, USA
| | - Kelley Saia
- Obstetrics and Gynecology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Elisha M Wachman
- Pediatrics, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
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22
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Conradt E, Crowell SE, Lester BM. Early life stress and environmental influences on the neurodevelopment of children with prenatal opioid exposure. Neurobiol Stress 2018; 9:48-54. [PMID: 30151420 PMCID: PMC6108075 DOI: 10.1016/j.ynstr.2018.08.005] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 08/13/2018] [Accepted: 08/13/2018] [Indexed: 12/17/2022] Open
Abstract
Prenatal opioid exposure has reached epidemic proportions. In the last 10 years, there has been a 242% increase in the number of babies born with the drug withdrawal syndrome known as Neonatal Opioid Withdrawal Syndrome (NOWS). Developmental outcome studies of infants with prenatal opioid exposure are limited by methodological issues including small sample sizes and lack of control for confounding variables such as exposure to poverty and maternal psychopathology. Thus, there is a critical gap in the literature that limits our ability to predict short-term effects of opioid exposure. Here we review direct neurotoxic, indirect, and stress-related pathophysiologies of prenatal opioid exposure. We describe the literature on short and long-term neurodevelopmental outcomes of children with prenatal opioid exposure, highlighting sex differences and the role of early life stress. We conclude by prioritizing avenues for future research for this group of underserved women and their children at risk for neurodevelopmental delays.
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Affiliation(s)
| | | | - Barry M. Lester
- The Brown Center for the Study of Children at Risk, Providence, RI, USA
- Department of Psychiatry, Warren Alpert Medical School of Brown University, Providence, RI, USA
- Department of Pediatrics, Warren Alpert Medical School of Brown University, Providence, RI, USA
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Litzky JF, Deyssenroth MA, Everson TM, Lester BM, Lambertini L, Chen J, Marsit CJ. Prenatal exposure to maternal depression and anxiety on imprinted gene expression in placenta and infant neurodevelopment and growth. Pediatr Res 2018; 83. [PMID: 29538358 PMCID: PMC5959758 DOI: 10.1038/pr.2018.27] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BackgroundDepression and/or anxiety during pregnancy have been associated with impaired fetal growth and neurodevelopment. Because placental imprinted genes play a central role in fetal development and respond to environmental stressors, we hypothesized that imprinted gene expression would be affected by prenatal depression and anxiety.MethodsPlacental gene expression was compared between mothers with prenatal depression and/or anxiety/obsessive compulsive disorder/panic and control mothers without psychiatric history (n=458) in the Rhode Island Child Health Study.ResultsTwenty-nine genes were identified as being significantly differentially expressed between placentae from infants of mothers with both depression and anxiety (n=54), with depression (n=89), or who took perinatal psychiatric medications (n=29) and control mother/infant pairs, with most genes having decreased expression in the stressed group. Among placentae from infants of mothers with depression, we found no differences in expression by medication use, indicating that our results are related to the stressor rather than the treatments. We did not find any relationship between the stress-associated gene expression and neonatal neurodevelopment, as measured using the Neonatal Intensive Care Unit Network Neurobehavioral Scale.ConclusionsThis variation in expression may be part of an adaptive mechanism by which the placenta buffers the infant from the effects of maternal stress.
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Affiliation(s)
- Julia F Litzky
- Department of Epidemiology, Geisel School of Medicine at Dartmouth College, Hanover, NH
| | - Maya A Deyssenroth
- Department of Environmental Medicine and Public Health; Icahn School of Medicine at Mount Sinai; New York, NY
| | - Todd M Everson
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Barry M. Lester
- Center for the Study of Children at Risk, Warren Alpert Medical School of Brown University, Providence, RI
| | - Luca Lambertini
- Department of Environmental Medicine and Public Health; Icahn School of Medicine at Mount Sinai; New York, NY,Department of Obstetrics, Gynecology and Reproductive Science; Icahn School of Medicine at Mount Sinai; New York; NY
| | - Jia Chen
- Department of Environmental Medicine and Public Health; Icahn School of Medicine at Mount Sinai; New York, NY,Department of Pediatrics; Icahn School of Medicine at Mount Sinai; New York, NY
| | - Carmen J Marsit
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA,Corresponding Author: Carmen Marsit, 1518 Clifton Road, CNR 202, Atlanta, GA 30322, Phone: (404) 712-8912, Fax: (404) 727-8744,
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Abu Jawdeh EG, Westgate PM, Pant A, Stacy AL, Mamilla D, Gabrani A, Patwardhan A, Bada HS, Giannone P. Prenatal Opioid Exposure and Intermittent Hypoxemia in Preterm Infants: A Retrospective Assessment. Front Pediatr 2017; 5:253. [PMID: 29270395 PMCID: PMC5723668 DOI: 10.3389/fped.2017.00253] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 11/10/2017] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Intermittent hypoxemia (IH) is defined as episodic drops in oxygen saturation (SpO2). Preterm infants are at increased risk for IH due to their immature respiratory control/apnea of prematurity. The clinical relevance of IH is a relatively new observation with rising evidence linking IH to neonatal morbidities and long-term impairment. Hence, assessing factors that influence IH in preterm infants is imperative. Given the epidemic of opioid misuse in the USA, there is an urgent need to understand the impact of prenatal opioid exposure on neonatal outcomes. Hence, we wanted to assess the relationship between isolated prenatal opioid exposure and IH in preterm infants. METHODS In order to accurately calculate IH, SpO2 data were prospectively collected using high-resolution pulse oximeters during the first 8 weeks of life in preterm infants less than 30 weeks gestational age. Data related to prenatal opioid misuse were retrospectively collected from medical charts. Infants with tobacco or poly-drug exposure were excluded. The primary outcome measure is percent time spent with SpO2 below 80% (%time-SpO2 < 80). The secondary outcome measure is the number of severe IH events/week with SpO2 less than 80% (IH-SpO2 < 80). RESULTS A total of 82 infants with isolated opioid exposure (n = 14) or who were unexposed (n = 68) were included. There were no significant differences in baseline characteristics between opioid exposed and unexposed groups. There was a statistically significant increase of 0.23 (95% CI: 0.03, 0.43, p = 0.03) in mean of the square root of %time-SpO2 < 80. The number of IH-SpO2 < 80 events was higher in the opioid exposed group (mean difference = 2.95, 95% CI: -0.35, 6.25, p-value = 0.08), although statistical significance was not quite attained. CONCLUSION This study shows that preterm infants prenatally exposed to opioids have increased IH measures compared to unexposed infants. Interestingly, the increased IH in the opioid exposed group persists beyond the immediate postnatal period.
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Affiliation(s)
- Elie G Abu Jawdeh
- Division of Neonatology, Department of Pediatrics, University of Kentucky, Lexington, KY, United States
| | - Philip M Westgate
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, KY, United States
| | - Amrita Pant
- Division of Neonatology, Department of Pediatrics, University of Kentucky, Lexington, KY, United States
| | - Audra L Stacy
- College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Divya Mamilla
- Children's Hospital of Michigan, Detroit, MI, United States
| | - Aayush Gabrani
- Department of Pediatrics, New Jersey Medical School, Newark, NJ, United States
| | - Abhijit Patwardhan
- Department of Biomedical Engineering, College of Engineering, University of Kentucky, Lexington, KY, United States
| | - Henrietta S Bada
- Division of Neonatology, Department of Pediatrics, University of Kentucky, Lexington, KY, United States
| | - Peter Giannone
- Division of Neonatology, Department of Pediatrics, University of Kentucky, Lexington, KY, United States
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