Eat, Sleep, Console model for neonatal opioid withdrawal syndrome: a meta-analysis

Background

The rising incidence of drug abuse among pregnant women has rendered neonatal opioid withdrawal syndrome a significant global health concern.

Methods

Databases including PubMed, Web of Science, the Cochrane Library, Embase, Elton B. Stephens. Company (EBSCO), China National Knowledge Infrastructure (CNKI), and Wanfang were searched for comparative studies of the Eat, Sleep, Console model vs. traditional assessment tools for neonatal opioid withdrawal syndrome. Two reviewers conducted literature searches, screened according to the inclusion criteria, extracted data, and independently verified accuracy. All meta-analyses were conducted using Review Manager Version 5.4.

Results

In total, 18 studies involving 4,639 neonates were included in the meta-analysis. The Eat, Sleep, Console model demonstrated superior outcomes in assessing neonatal opioid withdrawal syndrome, significantly reducing the need for pharmacological treatment [risk ratio = 0.44, 95% confidence interval (CI) = 0.34-0.56, P < 0.001], decreasing the length of hospital stay [standard mean difference (SMD) = -2.10, 95% CI = -3.43 to -0.78, P = 0.002], and shortening the duration of opioid treatment (SMD = -1.33, 95% CI = -2.22 to -0.45, P = 0.003) compared to the Finnegan Neonatal Abstinence Scoring System.

Conclusions

The Eat, Sleep, Console model is more effective than the Finnegan Neonatal Abstinence Scoring System in improving the assessment and management of neonatal opioid withdrawal syndrome.

The Effect of Maternal Adverse Childhood Experiences (ACEs) on Substance Use During Pregnancy

OBJECTIVES

To analyze adverse childhood experiences (ACEs) among mothers of newborns referred to a hospital's child protection team (CPT) for suspected substance exposure. Researchers hypothesized that a higher prevalence of these mothers have ≥ 4 ACEs than female counterparts in the general population. The study team also explored whether associations existed between type of maternal ACEs and substance use in pregnancy.

METHODS

Retrospective review of infant referrals to the CPT in the 3 years after adding an ACEs questionnaire to the consultation process. Bivariate analyses and multivariate logistic regression models examined associations between prenatal substance use and maternal ACEs prevalence, controlling for demographics.

RESULTS

Data from 222 infants (four sets of twins) and 218 mothers were analyzed. Half (50.0%) the infants had withdrawal symptoms. Most (67.0%) women had positive toxicology screens, while 85.0% reported prenatal substance use. Half (50.9%) the mothers reported ≥ 4 ACEs and these individuals had significantly higher odds of cannabinoid use [adjusted odds ratio (aOR), 3.7; 95%CI 2.0, 6.9, p < 0.001) than those with < 4 ACEs. A significant association was found between substance use and ACEs in the household challenges category (p = 0.03), especially parental separation/divorce (p < 0.001).

CONCLUSIONS FOR PRACTICE

As hypothesized, a higher prevalence of mothers referred to the CPT had ≥ 4 ACEs than women in the general population (50.9% vs. 15.2%), and a large proportion had used substances while pregnant. Routine prenatal ACEs screening and universal, nonpunitive toxicology testing of infants and mothers at birth may provide opportunities for intervention while reducing the transgenerational impact of ACEs.

Trends in Drug Tests among Children: A 22-Year Retrospective Analysis

There are several pathophysiological outcomes associated with substance abuse including metabolic disbalance, neurodegeneration, and disordered redox. Drug use in pregnant women is a topic of great concern due to developmental harm which may occur during gestation and the associated complications in the neonate after delivery. We sought to determine what the trajectory of drug use is like in children aged 0-4 years and mothers of neonates. Urine drug screen (UDS) results were obtained of our target demographic during 1998-2011 and 2012-2019 from LSU Health Sciences Center in Shreveport (LSUHSC-S). Statistical analysis was performed using R software. We observed an increase in cannabinoid-positive UDS results in both Caucasian (CC) and African American (AA) groups between 1998-2011 and 2012-2019 periods. Cocaine-positive UDS results decreased in both cohorts. CC children had higher UDS positive results for opiates, benzodiazepines, and amphetamines, while AA children had a higher percentage for illicit drugs such as cannabinoids and cocaine. Neonate's mothers had similar UDS trends to that in children during 2012-2019. Overall, while percentage of positive UDS results for both AA and CC 0-4 year old children started to decline for opiate, benzodiazepine, and cocaine during 2012-2019, cannabinoid- and amphetamine (CC)-positive UDS steadily increased. These results suggest a shift in the type of drug use by mothers from opiates, benzodiazepines, and cocaine to cannabinoids and/or amphetamines. We also observed that 18-year-old females who tested positive for opiates, benzodiazepine, or cocaine had higher than average chances of testing positive for cannabinoids later in life.

Prenatal heroin exposure alters brain morphology and connectivity in adolescent mice

The United States is experiencing a dramatic increase in maternal opioid misuse and, consequently, the number of individuals exposed to opioids in utero. Prenatal opioid exposure has both acute and long-lasting effects on health and wellbeing. Effects on the brain, often identified at school age, manifest as cognitive impairment, attention deficit, and reduced scholastic achievement. The neurobiological basis for these effects is poorly understood. Here, we examine how in utero exposure to heroin affects brain development into early adolescence in a mouse model. Pregnant C57BL/6J mice received escalating doses of heroin twice daily on gestational days 4-18. The brains of offspring were assessed on postnatal day 28 using 9.4 T diffusion MRI of postmortem specimens at 36 μm resolution. Whole-brain volumes and the volumes of 166 bilateral regions were compared between heroin-exposed and control offspring. We identified a reduction in whole-brain volume in heroin-exposed offspring and heroin-associated volume changes in 29 regions after standardizing for whole-brain volume. Regions with bilaterally reduced standardized volumes in heroin-exposed offspring relative to controls include the ectorhinal and insular cortices. Regions with bilaterally increased standardized volumes in heroin-exposed offspring relative to controls include the periaqueductal gray, septal region, striatum, and hypothalamus. Leveraging microscopic resolution diffusion tensor imaging and precise regional parcellation, we generated whole-brain structural MRI diffusion connectomes. Using a dimension reduction approach with multivariate analysis of variance to assess group differences in the connectome, we found that in utero heroin exposure altered structure-based connectivity of the left septal region and the region that acts as a hub for limbic regulatory actions. Consistent with clinical evidence, our findings suggest that prenatal opioid exposure may have effects on brain morphology, connectivity, and, consequently, function that persist into adolescence. This work expands our understanding of the risks associated with opioid misuse during pregnancy and identifies biomarkers that may facilitate diagnosis and treatment.

Early Postnatal Outcome and Care after in Utero Exposure to Lithium: A Single Center Analysis of a Belgian Tertiary University Hospital

Knowledge of the impact of in utero exposure to lithium during the postnatal period is limited. Besides a possible teratogenic effect during the first trimester, exposure during the second and third trimesters might lead to neonatal effects. Uniform guidelines for postnatal management of these neonates are lacking. The aim was to retrospectively describe all neonates admitted to the University Hospitals Leuven after in utero exposure to lithium (January 2010 to April 2020), and to propose a postnatal care protocol. Descriptive statistics were performed. For continuous parameters with serial measurements, median population values were calculated. In total, 10 mother-neonate pairs were included. The median gestational age was 37 (interquartile range, IQR, 36-39) weeks. Neonatal plasma lithium concentration at birth was 0.65 (IQR 0.56-0.83) mmol/L with a median neonate/mother ratio of 1.02 (IQR 0.87-1.08). Three neonates needed respiratory support, 7/10 started full enteral (formula) feeding on day 1. The median length of neonatal stay was 8.5 (IQR 8-12) days. One neonate developed nephrogenic diabetes insipidus. This study reported in detail the postnatal characteristics and short-term neonatal outcomes. A postnatal care protocol was proposed, to enhance the quality of care for future neonates, and to guide parental counselling. Future prospective protocol evaluation is needed.

Global research production in neonatal abstinence syndrome: A bibliometric analysis

BACKGROUND

Recently, neonatal abstinence syndrome (NAS) emerged as a significant global concern with a dramatic increase in healthcare expenditures. The incidence of the NAS has increased notably in the past decade and emergence as a global public health problem.

AIM

To evaluate the development and trend of global NAS research from 1958 to 2019 by bibliometric analysis.

METHODS

Analyzed aspects included publication output per year, language, document types, journals, countries/territories, h-index, authors, and top research priorities. The VOSviewer was used to determine the top research priorities, and trends, and to present bibliometric networks concerning various dimensions, such as co-authorship, authors, and countries.

RESULTS

A total of 1738 articles were retrieved in the Scopus database from 1958 to 2019. It was found that the great majority of the total NAS documents (n = 1295) were original articles followed by reviews (n = 268) and letters (n = 48). The most productive countries in the NAS field were the United States (n = 833), Canada (n = 112), the United Kingdom (n = 111), and Germany (n = 77). Treatment and hospital outcomes in NAS, evidence-based nurse-driven interventions for the care of newborns with NAS, and a systematic reviews and network meta-analysis for therapeutic approaches of NAS were found in recent years (after 2010), compared with terms such as pathophysiology, mechanisms of NAS, and signs and symptoms in the early years.

CONCLUSION

Treatment and pediatric outcomes and the effectiveness of pharmacological treatment may be frontiers in the NAS field, and continued efforts from researchers are needed in those topics.

Global research production in neonatal abstinence syndrome: A bibliometric analysis

BACKGROUND

Recently, neonatal abstinence syndrome (NAS) emerged as a significant global concern with a dramatic increase in healthcare expenditures. The incidence of the NAS has increased notably in the past decade and emergence as a global public health problem.

AIM

To evaluate the development and trend of global NAS research from 1958 to 2019 by bibliometric analysis.

METHODS

Analyzed aspects included publication output per year, language, document types, journals, countries/territories, h-index, authors, and top research priorities. The VOSviewer was used to determine the top research priorities, and trends, and to present bibliometric networks concerning various dimensions, such as co-authorship, authors, and countries.

RESULTS

A total of 1738 articles were retrieved in the Scopus database from 1958 to 2019. It was found that the great majority of the total NAS documents (n = 1295) were original articles followed by reviews (n = 268) and letters (n = 48). The most productive countries in the NAS field were the United States (n = 833), Canada (n = 112), the United Kingdom (n = 111), and Germany (n = 77). Treatment and hospital outcomes in NAS, evidence-based nurse-driven interventions for the care of newborns with NAS, and a systematic reviews and network meta-analysis for therapeutic approaches of NAS were found in recent years (after 2010), compared with terms such as pathophysiology, mechanisms of NAS, and signs and symptoms in the early years.

CONCLUSION

Treatment and pediatric outcomes and the effectiveness of pharmacological treatment may be frontiers in the NAS field, and continued efforts from researchers are needed in those topics.

Factors in children with a history of neonatal abstinence syndrome at 10 years of age: Evidence from the maternal lifestyle study

PURPOSE

Few studies have addressed the impact of prior prenatal substance exposure and current household environment on neurodevelopmental health in children with a history of neonatal abstinence syndrome (NAS). This study aimed to describe the prenatal exposures, household environment, and neurodevelopmental health at 10 years of age among children with a history of NAS.

DESIGN AND METHODS

This study was a retrospective, descriptive design using data from the Maternal Lifestyle Study. Descriptive analyses were conducted. A total of 234 children with a history of NAS were included in this study. Variables selected based on the socio-ecological model included prenatal exposures, household environment, and neurodevelopmental health outcomes.

RESULTS

In this sample, most children were male (63%) with prenatal polysubstance exposure (80%). The majority lived in a home where substance use occurred (68%). Children experienced abnormal cognitive development (26%), language disorders (24%), learning disorders (23%), and abnormal behavioral development (16%).

IMPLICATIONS

This study extends the description of children with a history of NAS beyond 5 years of age. Pediatric nurses can ensure that children with a history of NAS receive neurodevelopmental screening up to and beyond 10 years of age.

Elucidating the context for implementing nonpharmacologic care for neonatal opioid withdrawal syndrome: a qualitative study of perinatal nurses

BACKGROUND

Up to 95% of neonates exposed to opioids in utero experience neonatal opioid withdrawal syndrome at birth. Nonpharmacologic approaches (e.g., breastfeeding; rooming-in; skin-to-skin care) are evidence-based and should be implemented. These approaches, especially breastfeeding, rely on engagement of the neonates' mothers to help deliver them. However, little is known about the structural and social dynamic context barriers and facilitators to implementing maternal-delivered nonpharmacologic care.

METHODS

Using a qualitative descriptive design, perinatal nurses from a Midwest United States hospital family birthing center, neonatal intensive care unit, and inpatient pediatric unit were interviewed. These units were involved in caring for mothers and neonates affected by opioid use. Telephone interviews followed a semi-structured interview guide developed for this study, were audio-recorded, and lasted about 30-60 min. Interviews were transcribed verbatim and independently analyzed by five investigators using the constant comparative method. Themes were discussed until reaching consensus and subsequently mapped to a conceptual model adapted for this study.

RESULTS

Twenty-one nurses participated in this study (family birth center, n = 9; neonatal intensive care, n = 6; pediatrics, n = 6). Analysis resulted in four major themes: 1) Lack of education and resources provided to staff and mothers; 2) Importance of interdisciplinary and intradisciplinary care coordination; 3) Flexibility in nurse staffing models for neonatal opioid withdrawal syndrome; and 4) Unit architecture and layout affects maternal involvement. Minor themes supported each of the four major themes. All themes mapped to the conceptual model.

CONCLUSIONS

This study provides a more comprehensive understanding of the barriers and facilitators affecting implementation of maternal involvement in nonpharmacologic care of newborns with neonatal opioid withdrawal syndrome. Future efforts implementing nonpharmacologic approaches must consider the context factors affecting implementation, including structural and social factors within the units, hospital, and broader community.

Informing the Development of a Standardized Clinical Definition of Neonatal Abstinence Syndrome: Protocol for a Modified-Delphi Expert Panel

Background

Neonatal abstinence syndrome (NAS) is a postnatal withdrawal syndrome that most commonly results from prenatal opioid exposure. Every 15 minutes, an infant is born in the United States with signs of NAS. The field lacks a standardized clinical definition of NAS, complicating discussions on programmatic and policy development to support opioid-exposed mothers and infants.

Objective

The goal of this paper is to describe a protocol for a systematic expert panel process to inform the development of a clinical definition of NAS.

Methods

We will conduct two three-round online modified-Delphi panels using the ExpertLens system and will follow the recommendations for Conducting and REporting of DElphi Studies (CREDES). One panel will focus on developing key components of a clinical definition of NAS, and the second panel will focus on neonatal opioid withdrawal syndrome (NOWS), which is a term that has come into use to differentiate opioid-exposed infants from infants exposed to other substances in utero. However, there is lack of agreement on the precise clinical definition of NOWS and how it is distinct from or overlaps with NAS. Each panel will complete two rating rounds and a discussion round using a similar protocol. We will analyze all rating data descriptively and determine the presence of agreement within and between the two panels. We will also perform thematic analysis of the qualitative comments to contextualize the panel findings.

Results

The panels were convened between October 29 and December 17, 2020. Their results were disseminated and discussed at a national conference on NAS that took place on March 17-18, 2021.

Conclusions

A standardized clinical definition of NAS will help to better characterize NAS incidence and to design effective clinical, public health, and policy interventions to support opioid-exposed mother-infant dyads.

International Registered Report Identifier (IRRID)

DERR1-10.2196/25387

Maternal opioid use disorder: Placental transcriptome analysis for neonatal opioid withdrawal syndrome

Excessive prenatal opioid exposure may lead to the development of Neonatal Opioid Withdrawal Syndrome (NOWS). RNA-seq was done on 64 formalin-fixed paraffin-embedded placental tissue samples from 32 mothers with opioid use disorder, with newborns with NOWS that required treatment, and 32 prenatally unexposed controls. We identified 93 differentially expressed genes in the placentas of infants with NOWS compared to unexposed controls. There were 4 up- and 89 downregulated genes. Among these, 7 genes CYP1A1, APOB, RPH3A, NRXN1, LINC01206, AL157396.1, UNC80 achieved an FDR p-value of <0.01. The remaining 87 genes were significant with FDR p-value <0.05. The 4 upregulated, CYP1A1, FP671120.3, RAD1, RN7SL856P, and the 10 most significantly downregulated genes were RNA5SP364, GRIN2A, UNC5D, DMBT1P1, MIR3976HG, LINC02199, LINC02822, PANTR1, AC012178.1, CTNNA2. Ingenuity Pathway Analysis identified the 7 most likely to play an important role in the etiology of NOWS. Our study expands insights into the genetic mechanisms of NOWS development.

Incidence and clinical manifestation of iatrogenic opioid withdrawal syndrome in mechanically ventilated patients

OBJECTIVE

The incidence of iatrogenic opioid withdrawal syndrome (IOWS) in mechanically ventilated adults has been questioned in settings driven by analgosedation strategies. This study aimed to describe the incidence, risk factors and clinical impact of IOWS in mechanically ventilated adults.

METHODS

This prospective, observational study was performed between 1 January and 31 August 2018. IOWS was identified based on the presence of at least three signs or symptoms according to the Diagnostic and Statistical Manual 5th edition (DSM-5) criteria after opioid discontinuation or rate reduction. Incidence of IOWS, patient characteristics, opioid administration, and the impact of IOWS on the duration of mechanical ventilator and length of stay in the intensive care unit (ICU) were collected.

RESULTS

Thirteen out of 55 patients (23.6%) manifested withdrawal symptoms. Two patients in the non-withdrawal group also developed hypertensive urgency after opioid discontinuation. Patients who received rapid once-daily weaning, especially rate reduction more than 50 µg as fentanyl equivalent per hour, were associated with IOWS. However, there was no statistically significant difference in ventilator-free days and ICU-free days.

CONCLUSIONS

These findings showed that approximately one-fourth of mechanically ventilated patients who received opioid infusion experienced IOWS. Monitoring for IOWS is recommended especially in patients who received rapid weaning rate of opioids. Future studies to develop IOWS assessment tools with the change of hemodynamic parameters should be performed.

TRIAL REGISTRATION

This trial was registered in ClinicalTrials.gov: identifier NCT03374722, date of registration 15 December 2018.

Pharmacometric Evaluation of Umbilical Cord Blood Concentration-Based Early Initiation of Treatment in Methadone-Exposed Preterm Neonates

In methadone-exposed preterm neonates, early identification of those at risk of severe neonatal abstinence syndrome (NAS) and use of a methadone dosing regimen that can provide effective and safe drug exposure are two important aspects of optimal care. To this end, we reviewed 17 methadone dosing recommendations in the international guidelines and literature and explored their variability in key dosing strategies. We selected three of the reviewed dosing regimens for their pharmacokinetics (PK) characteristics and their exposure-response relationship in three gestational age groups of preterm neonates (28, 32 and 36 gestational age weeks) at risk for development of severe NAS (defined as an umbilical cord methadone concentration of ≤60 ng/mL, following fetal exposure). We applied early (12 h after birth) vs. typical (36 h after birth) initiation of treatment. We observed that use of universally recommended dosing regimens in preterm neonates can result in under- or over-exposure. Use of a PK-guided dosing regimen resulted in effective target exposures within 24 h after birth with early initiation of treatment (12 h after birth). Future prospective studies should explore the incorporation of umbilical cord methadone concentrations for early identification of preterm neonates at risk of developing severe NAS and investigate the use of a PK-guided methadone dosing regimen, so that treatment failure, prolonged length of stay and opioid over-exposure can be avoided.

A Retrospective Review Following the Addition of Clonidine to a Neonatal Abstinence Syndrome Treatment Algorithm

Objective: To investigate the outcomes associated with the implementation of a neonatal abstinence syndrome (NAS) treatment algorithm utilizing dual therapy with morphine sulfate and clonidine in a level four neonatal intensive care unit (NICU). Study Design: A cohort of neonates (≥35 weeks gestation) born at an academic tertiary medical center between January 1, 2015 and December 31, 2018 who were diagnosed with NAS were retrospectively evaluated following the implementation of a new NAS treatment algorithm. Neonates were categorized in two groups based on if they were treated pre- or post-implementation of the protocol. The primary efficacy outcome was length of hospital stay. Secondary outcomes included the incidence of adverse drug reactions, length of treatment for NAS, and maximum as well as total cumulative dose of each medication used to treat NAS. Results: The implementation of this NAS treatment algorithm significantly reduced the length of hospital stay (30 days vs. 20 days, p = 0.001). In addition, there was a significant decrease in duration of morphine sulfate exposure as well as cumulative dose of morphine required to successfully treat a neonate with NAS in the post-implementation group (26 days vs. 15 days, p = 0.002 and 6.9 mg/kg vs. 3.4 mg/kg, p = 0.031). Conclusion: Addition of clonidine to morphine sulfate as initial therapy for NAS significantly reduced the cumulative exposure as well as duration of exposure to morphine sulfate compared to morphine monotherapy and decrease length of hospital stay.

Opioid-Induced Hearing Loss and Neonatal Abstinence Syndrome: Clinical Considerations for Audiologists and Recommendations for Future Research

Purpose Over the last two decades, the number of Americans misusing opioids has reached epidemic levels. With such drastic increases in opioid misuse, audiologists are more likely to have patients with opioid-induced hearing loss or neonatal abstinence syndrome (NAS) than in previous years. More attention is needed on how these increases might influence clinical practice and such a discussion could be useful for audiologists. The goal of this article, therefore, is to summarize what is currently known regarding the relationship between opioid misuse and audiology to help guide hearing health care providers (with a particular focus on opioid-induced hearing loss and NAS). This article (a) summarizes the overlap in opioid misuse and hearing loss populations, (b) describes the evidence linking opioid misuse to hearing loss, (c) discusses clinical implications that opioid-induced hearing loss and NAS have for practicing audiologists, and (d) recommends directions for future audiological research on opioid-induced hearing loss and NAS. Conclusions There is considerable overlap between populations at-risk for hearing loss and opioid misuse. Additionally, compelling evidence exists linking opioid misuse to hearing loss, but the specific causal mechanisms remain unclear, indicating a need for additional research. This article attempts to fill a gap in the audiological literature and has the potential to serve as a guide for hearing health care providers to make more informed clinical decisions regarding patients with opioid-induced hearing loss and NAS. Clinicians may wish to consider the concerns raised in this article before intervening with such concerns, especially in the absence of best practice protocols.

Citalopram intoxication in four week old infant

Background

In contrast to intoxications in toddlers which can be due to accidental ingestions, many intoxications in infants are due to medication errors. To our knowledge, this is the first case report of a citalopram intoxication in an infant, and may offer new insight on possible screening methods for intoxication as well as pharmacokinetics of citalopram in small infants.

Case presentation

This case report describes an unintentional citalopram intoxication in a 4 week old infant due to a vitamin D drops ‘look alike’ error. The infant showed extreme jitteriness and opisthotonus at presentation, as well as prolonged signs of gastro-oesophageal reflux. No cardiac rhythm disturbances or convulsions were seen. The clinical course combined with Finnegan scores was correlated to and supported by pharmacokinetic and pharmacokinetic data of citalopram in the patient.

Conclusions

Using Finnegan scores in general pediatric practice could help objectify follow-up of acute intoxications in young infants with neurological symptoms.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-020-02439-5.

Using Simulation in Training Pediatric Residents on Neonatal Abstinence Syndrome Scoring: An Experimental Study

BACKGROUND

Neonatal abstinence syndrome (NAS) is characterized by significant physiological and behavioral signs involving multiple-organ systems in neonates following a prenatal exposure to opioids and other nonopioid drugs. Neonatal abstinence syndrome can result in serious morbidity, and even death, if unrecognized and untreated. The purpose of this study was to develop a simulation model of a standard video training of the Finnegan Neonatal Abstinence Scoring System (FNAS) and investigate the perceptions of comfort and competency of pediatric residents undergoing video or simulation training.

METHODS

Thirty-one pediatric and medicine-pediatric residents participated in this single-blinded randomized intervention study. The experimental group completed demonstrated simulation while the control group received the traditional video instruction. Both groups completed FNAS scoring on a case of a neonate with NAS. The FNAS scores of residents were compared with the scores of 2 expert raters. Pre- and posttraining and preference surveys were obtained from all participants.

RESULTS

Both experimental and control groups scored the FNAS scenario similarly and were also similar to the expert raters. Both groups also reported comparable levels of comfort and competency after the training, though first-year residents reported greater improvement than upper-level residents. The FNAS scores from expert raters were identical for the simulation and video scenarios.

IMPLICATIONS FOR PRACTICE

Although this study showed that a simulation training module can be used as a standardized teaching method to administer the FNAS, it can be cost-prohibitive and daunting to produce. Nursing professionals need to be aware of medical education training around FNAS due to the interdisciplinary nature of care for neonates with NAS. Institutions should consider implementing a diversity of practices and models with an interdisciplinary approach to training assessment of the neonate with NAS.

IMPLICATIONS FOR RESEARCH

A more hands-on, less cost-prohibitive simulation training needs to be developed to teach FNAS administration with a broader range of professionals including interdisciplinary teams of nursing and medical professionals.

Behavioral development in children with prenatal substance exposure and neonatal abstinence syndrome: Associated factors and implications

PROBLEM

Prenatal substance exposure and neonatal abstinence syndrome (NAS) are risk factors for adverse behavioral outcomes in children at 24 months of age.

METHODS

The purpose of this study was to examine factors associated with abnormal behavioral development in children with prenatal substance exposure or NAS through 10 years of age. A retrospective, nonexperimental, longitudinal design to examine the effects of prenatal substance exposure and NAS on behavioral development at 1, 5, and 10 years of age, while controlling for intrapersonal, interpersonal, community, organizational, and public policy characteristics. A hierarchical multivariate logistic regression model was used to evaluate the influence of substance exposure and NAS on behavioral outcomes.

FINDINGS

Abnormal behavioral development was predicted at 10 years of age with polysubstance exposure to three substances (odds ratio [OR] = 2.711, p < 0.01) and NAS (OR = 2.077, p < .001).

CONCLUSION

Psychiatric nursing care for children with prenatal substance exposure and NAS should include implementation of early and continued behavioral evaluation and childhood trauma and adversity surveillance in children through middle childhood.

Cognitive Outcomes of Young Children After Prenatal Exposure to Medications for Opioid Use Disorder: A Systematic Review and Meta-analysis

IMPORTANCE

The number of children with prenatal opioid exposure to medication for addiction treatment (MAT) with methadone and buprenorphine for maternal opioid use disorder is increasing, but the associations of this exposure with cognitive outcomes are not well understood.

OBJECTIVE

To examine the strength and consistency of findings in the medical literature regarding the association of prenatal exposure to MAT with early childhood cognitive development, particularly when accounting for variables outside MAT exposure.

DATA SOURCES

A search strategy obtained publications from PubMed, CINAHL, PsycINFO, Web of Science, and Embase from January 1972 to June 2019. Reference lists from identified articles were searched.

STUDY SELECTION

Inclusion criteria were cohort studies, studies including children aged 1 to 60 months with at least 2 months of prenatal MAT exposure, studies using standardized direct-observation testing scales, and studies reporting means and SDs. Case reports, case series, historical controls, and reviews were excluded.

DATA EXTRACTION AND SYNTHESIS

Two authors independently selected studies for inclusion, extracted data, and assessed study quality. Data extracted included demographic characteristics, covariates, sources of bias, and effect estimates. Meta-analysis was performed using random-effects models. This study was conducted according to the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Data extraction and synthesis were conducted between January 2018 and August 2019.

MAIN OUTCOMES AND MEASURES

Cognitive test scores and demographic variability between exposed and unexposed groups.

RESULTS

A total of 16 unique cohorts, described in 27 articles and including 1086 children (485 [44.7%] with MAT exposure), were included in a quantitative synthesis. On meta-analysis, MAT exposure was associated with lower cognitive development scores (pooled standardized mean difference, -0.57; 95% CI, -0.93 to -0.21; I2 = 81%). Multiple subanalyses on demographic characteristics (ie, maternal education, race/ethnicity, socioeconomic status, prenatal tobacco exposure, infant sex) were conducted. In the subanalysis of studies with comparable prenatal exposure to tobacco smoke, the association of MAT exposure with cognitive scores was no longer statistically significant and became homogeneous (standardized mean difference, -0.11; 95% CI, -0.42 to 0.20; I2 = 0%).

CONCLUSIONS AND RELEVANCE

In this study, predefined subanalyses demonstrated how poor recruitment, particularly imbalances in maternal tobacco use, could contribute to a negative overall association of cognitive development test scores with prenatal MAT exposure. Promoting tobacco cessation for pregnant women with opioid use disorder should be prioritized in this high-risk population.

The Effects of Neonatal Abstinence Syndrome on Language Delay from Birth to 10 Years

PURPOSE

To examine the longitudinal effects of a history of neonatal abstinence syndrome (NAS) on language development over the first 10 years of life.

DESIGN AND METHODS

This study used a retrospective, longitudinal design. The data were analyzed using generalized linear mixed models (GLMM) to examine the effects of NAS on language delay over time while controlling for demographic, prenatal, and household factors.

RESULTS

There was a significant difference in the pattern of language delays over time between the NAS and non-NAS groups. At the age of 5 (est: -1.788, p < .001), children with a history of NAS had a decreased log odds of developing language delays than those without NAS. Conversely, compared with age 1, at the age of 10 (est: 1.098 p < .001), children with a history of NAS had an increased log odds of developing language delays than those without NAS.

CONCLUSIONS

Children with a history of NAS had significantly different rates of language delays over time. Children with a history of NAS had significantly higher rates of language delays at 10 years than children without NAS.

PRACTICE IMPLICATIONS

There is a need to increase developmental surveillance, along with referrals for specialized services, for children with a history of NAS through middle childhood.

Treating infants with neonatal abstinence syndrome: an examination of three protocols

OBJECTIVE

Describe the characteristics of infants with NAS and determine if treatment outcomes varied between three protocols.

STUDY DESIGN

Based on medical record data, infant treatment for NAS-related withdrawal reflected one of three protocols: (1) No rescue dose (n = 836, 52.7%): Prescriber ordered initiation and escalation doses and determined when infants were eligible for weaning, (2) Rescue dose (n = 233, 14.7%): No rescue dose with the addition of a prescriber-ordered rescue dose, (3) Rescue dose by order set (n = 516, 32.6%): Rescue dose with addition of nurse-assisted order of morphine during escalation.

RESULTS

The no rescue dose group had longer length of stay, days to wean, and inpatient days, and greater initial morphine dose than the two rescue dose groups (p < 0.001). Treatment outcomes between the two rescue dose protocols did not differ.

CONCLUSIONS

The benefits related to rescue dosing further inform the development of a standardized NAS treatment protocol.

The evolution of the science of kangaroo (mother) care (skin-to-skin contact)

In the early 1970s, researchers in Ohio, USA, investigated the effects of "Extra Contact" between mothers and their infants early after birth. The "Extra Contact" consisted of the skin-to-skin holding of the newborn infant on the mother's bare chest as soon as possible after birth. In the mid 1970s, Rey and Martinez in Bogota Colombia started investigating the same care method and they called it "Kangaroo Care" (KC). Infants are held upright, skin-to-skin on the mother's bare chest. KC, also referred to as Kangaroo Mother Care or Skin-to-Skin Contact, has been and continue to be investigated for its effects on a plethora of infant, maternal and family outcomes. Evolution of our understanding of the advantages of KC has dramatically changed the care of infants including at risk infants. This article provides a look at the past and present. It also provides insight on how we can shape the future to provide the optimal care for infants, mothers, and the whole family.

The United States opioid epidemic

The United States opioid epidemic is a nationwide public health crisis. Initially driven by increased consumption and availability of pharmaceutical opioids, an increasing number of opioid overdoses are now related to heroin and illicitly manufactured fentanyl and fentanyl analogs. Addressing this epidemic requires addressing the stigma associated with opioid use disorders and its treatment, improving access to efficacious treatment options, specifically methadone and buprenorphine, and reducing opioid overdose fatalities with distribution of the opioid antagonist and overdose reversal agent naloxone.

Eat, Sleep, Console Approach: A Family-Centered Model for the Treatment of Neonatal Abstinence Syndrome

BACKGROUND

The opioid epidemic in the United States has resulted in an increased number of drug-exposed infants who are at risk for developing neonatal abstinence syndrome (NAS). Historically, these infants have been treated with the introduction and slow weaning of pharmaceuticals. Recently, a new model called Eat, Sleep, Console (ESC) has been developed that focuses on the comfort and care of these infants by maximizing nonpharmacologic methods, increasing family involvement in the treatment of their infant, and prn or "as needed" use of morphine.

PURPOSE

The purpose of this evidenced-based practice brief was to summarize and critically review emerging research on the ESC method of managing NAS and develop a recommendation for implementing an ESC model.

METHODS

A literature review was conducted using PubMed, Cochrane, and Google Scholar with a focus on ESC programs developed for treating infants with NAS.

FINDING/RESULTS

Several studies were found with successful development and implementation of the ESC model. Studies supported the use of ESC to decrease length of stay, exposure to pharmacologic agents, and overall cost of treatment.Video Abstract Available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?videoId=32&autoPlay=true.

Opioid Use in Pregnant Women and Neonatal Abstinence Syndrome-A Review of the Literature

Opiate use during pregnancy has been an increasing problem over the last two decades, making it an important social and health concern. The use of such substances may have serious negative outcomes in the newborn, and clinical and cognitive conditions have been reported, including neonatal abstinence syndrome, developmental problems, and lower cognitive performance. These conditions are common when opiates are used during pregnancy, making the prescription of these kinds of drugs problematic. Moreover, the mother may develop opiate addiction, thus, increasing the likelihood of the infant being born with any of those conditions. This paper reviews the use of opiates during pregnancy and focuses mainly on the neonatal abstinence syndrome. First, the commonly prescribed opiates will be identified, namely those usually involved in cases of addiction and/or neonatal abstinence syndrome. Second, published approaches to deal with those problems will be presented and discussed, including the treatment of both the mother and the infant. Finally, we will outline the treatments that are safest and most efficient, and will define future goals, approaches, and research directions for the scientific community regarding this problem.

Comparison of outcomes between morphine and concomitant morphine and clonidine treatments for neonatal abstinence syndrome

AIM

To examine whether adding clonidine to the morphine regimen for treatment of neonatal abstinence syndrome (NAS) is associated with a shorter length of treatment compared with morphine alone.

METHODS

Using a retrospective cohort design, infants with NAS resulting from opioid exposure delivered between 2006 and 2015 (n = 174) were identified using the Nova Scotia Atlee Perinatal Database (NSAPD). Maternal and infant characteristics were collected from the NSAPD. The database was augmented with chart review for treatment information.

RESULTS

The incidence of NAS in the study population increased fivefold from 1.48/1000 live births in 2007 to 7.50/1000 live births in 2015. Of the 174 infants, 22 were treated with morphine and 100 were treated with morphine + clonidine. Longer length of treatment (p = 0.004) and higher peak morphine dose (p = 0.045) were observed in the combination group.

CONCLUSION

The increase in the incidence of NAS is consistent with recent published reports. The increase in length of treatment and peak morphine dose in the morphine + clonidine group is in marked contrast to previous work on this treatment combination. Further study on the impact of clinical characteristics such as methadone and antidepressant exposure on the association is warranted.

Buprenorphine for the Treatment of Neonatal Abstinence Syndrome

Objective: To summarize the available data for using buprenorphine in neonatal abstinence syndrome and discuss these data in context of the current standard of care therapies, oral morphine and oral methadone. Data Sources: A literature search was conducted using PubMed (1949-May 2018) and EMBASE (1980-May 2018). Combinations of the search terms “buprenorphine,” “neonatal,” and “neonatal abstinence syndrome” were used. Study Selection and Data Extraction: All full-length, English-language studies were included in this review. Data Synthesis: A total of 4 studies were included in this review including 1 retrospective cohort study, 2 prospective single-center open-label randomized trials, and 1 prospective single-center, double-blind study. Oral morphine was the comparator in 3 studies, and oral methadone was the comparator in one. Buprenorphine was associated with a significant reduction in duration of treatment in 3 of the 4 studies and was associated with a significant reduction in duration of hospital stay in 3 of the 4 studies. In the randomized, double-blinded trial, buprenorphine had a significantly reduced duration of treatment (15 vs 28 days, P < .001) and duration of hospital stay (21 vs 33 days, P < .001). The requirement of adjunct treatment was similar between groups in all 4 studies, and buprenorphine did not have any significant adverse reactions in comparison with morphine and methadone. Conclusions: Buprenorphine appears to be a safe option for treating neonatal abstinence syndrome that is potentially superior to the current standard of care therapies with respect to duration of treatment and hospital length of stay.

Modeling prenatal opioid exposure in animals: Current findings and future directions

The past decade has seen a drastic rise in the number of infants exposed to opioids in utero. It is unclear what lasting effect this exposure may have on these children. Animal models of prenatal opioid exposure may provide insight into potential areas of vulnerability. The present review summarizes the findings across animal models of prenatal opioid exposure, including exposure to morphine, methadone, buprenorphine, and oxycodone. Details regarding the drug, doses, and duration of treatment, as well as key findings, are summarized in tables with associated references. Finally, significant gaps in the current preclinical literature and future directions are discussed.

The Impact of Breastfeeding on Health Outcomes for Infants Diagnosed with Neonatal Abstinence Syndrome: A Review

Neonatal abstinence syndrome (NAS) is a neurologic condition resulting from prenatal exposure to opioids. The sudden cessation of opioids in neonates can lead to withdrawal symptoms affecting the neurologic, respiratory, and gastrointestinal systems. Rising opioid use in the United States has led to an increased incidence of infants born with NAS. Despite the growing incidence of NAS, there is a lack of standardized guidelines for intervention and management. Recent studies suggest that non-pharmacological methods should be used as first-line interventions for the reduction of NAS symptoms. Of the non-pharmacological methods, growing literature suggests that breastfeeding may have the potential to reduce symptom severity and improve outcomes. We searched the PubMed and Medline databases for experimental/quasi-experimental studies published from 1997-2018 regarding outcomes in breastfed versus formula-fed neonates with prenatal exposure to opioids. Seven retrospective studies fulfilling the inclusion criteria were reviewed. Collectively, the studies show a strong correlation between breastfeeding and a reduced length of hospital stay, a decreased severity of NAS presentation, and a decreased necessity of pharmacological interventions in infants diagnosed with NAS. From these findings, we recommend breastfeeding as an integral component of the early management of NAS.

Neonatal Abstinence Syndrome: Exploring Nurses' Attitudes, Knowledge, and Practice

BACKGROUND

As opioid abuse increases in the United States, the rate of neonatal abstinence syndrome (NAS) rises dramatically. Caring for infants with NAS and their families is a significant challenge to neonatal nurses.

PURPOSE

The purpose of this survey study was to explore attitudes and practice trends among nurses caring for infants with NAS. The study also aimed to identify any gaps in knowledge about NAS.

METHOD

An anonymous, cross-sectional survey study was conducted using a researcher-developed questionnaire. The survey questionnaire included 20 Likert-scale questions regarding nurses' attitudes, knowledge, and practice in care of infants with NAS, 1 case study with 3 questions, and 2 open-ended questions. Nurses, including advanced practice nurses and nurse leaders, were invited to participate at a regional neonatal nursing conference in the New England area.

RESULTS

A total of 54 participants responded, the majority being white, female, non-Hispanic, and bachelor's prepared. Many nurses shared concerns regarding the setting in which infants with NAS are cared for. Nurses expressed varying attitudes regarding interacting with the mothers but generally wanted to build a partnership with them. Nurses also reported a lack of standardized and consistent practice in care for infants with NAS. Three major themes were identified from open-ended questions, including environmental issues, relationship with the mother, and inconsistency in care.

IMPLICATIONS FOR PRACTICE

Further research is needed for nurses providing care to infants with NAS. Specific education programs are needed for nurses who are caring for infants with NAS.

IMPLICATIONS FOR RESEARCH

Further research is needed regarding the effects of NAS on nurses and other healthcare providers.

Infants in Drug Withdrawal: A National Description of Nurse Workload, Infant Acuity, and Parental Needs

Infants in drug withdrawal have complex physiological and behavioral states, requiring intensive nursing care. The study objectives were to describe acuity, parental needs, and nurse workload of infants in drug withdrawal compared with other infants. The design was cross-sectional and involved secondary nurse survey data from 6045 staff nurses from a national sample of 104 neonatal intensive care units. Nurses reported the care of 15 233 infants, 361 (2.4%) of whom were in drug withdrawal. Three-fourths of hospitals had at least 1 infant in drug withdrawal. In these hospitals, the mean number of infants in drug withdrawal was 4.7. Infant acuity was significantly higher among infants in drug withdrawal. Parents of infants in drug withdrawal required significantly more care to address complex social situations (51% vs 12%). The number of infants assigned to nurses with at least 1 infant in withdrawal (mean = 2.69) was significantly higher than typical (mean = 2.51). Given infant acuity and parental needs, policies legislating patient-to-nurse ratios should permit professional discretion on the number of patients to assign nurses caring for infants in drug withdrawal. Managers and charge nurses should consider the demands of caring for infants in drug withdrawal in assignment decisions and provide support and education.

Risk of neonatal drug withdrawal after intrauterine co-exposure to opioids and psychotropic medications: cohort study

Objectives To assess the impact of in utero co-exposure to psychotropic medications and opioids on the incidence and severity of neonatal drug withdrawal.Design Observational cohort study.Setting Nationwide sample of pregnancies in publicly insured women in the US, nested in the Medicaid Analytic eXtract (2000-10).Participants 201 275 pregnant women with public insurance who were exposed to opioids around the time of delivery and their liveborn infants.Interventions In utero exposure to psychotropic medications, in particular antidepressants, atypical antipsychotics, benzodiazepines, gabapentin, and non-benzodiazepine hypnotics (Z drugs), with prescriptions filled within the same time window as prescriptions for opioids.Main outcome measure Diagnosis of neonatal drug withdrawal in infants exposed in utero to opioids and psychotropic medications compared with opioids alone.Results The absolute risk for neonatal drug withdrawal ranged from 1.0% in infants exposed in utero to prescription opioids alone to 11.4% for those exposed to opioids co-prescribed with gabapentin. Among neonates exposed in utero to prescription opioids, the relative risk adjusted for propensity score was 1.34 (95% confidence interval 1.22 to 1.47) with concomitant exposure to antidepressants, 1.49 (1.35 to 1.63) with benzodiazepines, 1.61 (1.26 to 2.06) with gabapentin, 1.20 (0.95 to 1.51) with antipsychotics, and 1.01 (0.88 to 1.15) with Z drugs. In utero exposure to two or more psychotropic medications along with opioids was associated with a twofold increased risk of withdrawal (2.05, 1.77 to 2.37). The severity of the withdrawal seemed increased in neonates exposed to both opioids and psychotropic medications compared with opioids alone.Conclusions During pregnancy, the use of psychotropic medications in addition to prescription opioids is common, despite a lack of safety data. The current findings suggest that these drugs could further increase the risk and severity of neonatal drug withdrawal.