Infant autonomic functioning and neonatal abstinence syndrome

Infant and parent heart rates during a babywearing procedure: Evidence for autonomic coregulation

Babywearing is the practice of carrying an infant in a baby carrier, which may provide an inexpensive, nonpharmacological intervention for the parent-infant dyads to handle mental stressors, such as pain and anxiety, especially among vulnerable infants. This study investigated the influence of babywearing on parent-infant autonomic coregulation based on the changes in the HR of mother-infant and father-infant dyads for infants with neonatal abstinence syndrome (NAS). Guided by the Calming Cycle Theory as the framework, the correlation between parent HR and infant HR and the difference in the mother-infant dyad (n = 17) compared to the father-infant dyad (n = 8) were examined. Although only the mother-infant HRs reached statistical significance during babywearing (r̅ =.52, p = .03), both parent-infant dyads had strong correlations during babywearing (compared to pre- and post-babywearing conditions), indicating that babywearing, for parents and their infants with NAS, may influence autonomic coregulation.

Maternal opioid use during pregnancy and the risk of neonatal opioid withdrawal syndrome in the offspring

INTRODUCTION

Neonatal opioid withdrawal syndrome (NOWS) is caused by sudden cessation from in utero exposure to opioids. The indications for opioid use during pregnancy are diverse including medication for opioid use disorder and analgesia. The opioid dose typically depends on the indication, with higher doses used for medication for opioid use disorder and lower doses used for analgesia. The aim of this study was to investigate the relationship between maternal opioid dose during pregnancy and the risk of NOWS.

MATERIAL AND METHODS

We conducted a historical multicenter cohort study of neonates prenatally exposed to opioids in Eastern Denmark during a six-year period from 2013 to 2018. The data was extracted from reviewing the individual's medical record(s), which were identified through a search of the Danish National Patient Register. Four groups (quartiles) according to maternal opioid dose during the last four weeks prior to delivery were compared. Unadjusted and adjusted logistic regression analyses were conducted to examine the risk of NOWS while controlling for relevant covariates.

RESULTS

A total of 130 in utero opioid exposed neonates were included. The majority of the pregnant patients (88%) were treated with opioids for analgesic purposes. Overall, 52% of neonates developed NOWS. The cumulative incidence of NOWS was 21%, 28%, 67% and 91% at maternal average daily dose of morphine milligram equivalent during the last four weeks prior to delivery of 0.7-14 (group I), 14.3-38.6 (group II), 40-90 (group III) and 90.9-1440 (group IV), respectively. Compared to group I the adjusted odds (aOR) of NOWS increased significantly in group III (aOR 10.6 [2.9-39.1]) and group IV (aOR 37.8 [7.6-188.2]) but not in group II (aOR 1.5 [0.4-5.2]). No cases of NOWS were reported at maternal dose less than an average daily dose of five morphine milligram equivalent during the last four weeks prior to delivery. No significant changes in the incidence of NOWS were observed between 2013 and 2018.

CONCLUSIONS

The odds of neonatal opioid withdrawal syndrome increased significantly as the maternal average daily dose of morphine milligram equivalent during the last four weeks prior to delivery surpassed 40.

Sex-Related Differences in the Severity of Neonatal Opioid Withdrawal Syndrome: A Single-Center, Retrospective Cohort Study

OBJECTIVE

 Factors associated with the development and expression of Neonatal Opioid Withdrawal Syndrome (NOWS) are poorly understood. There are conflicting data on the role of infant sex in NOWS. Some studies have suggested that infant sex predicts NOWS severity and adverse outcomes, with male infants being more vulnerable. This study aimed to analyze if infant sex is associated with the severity of NOWS among those who require pharmacologic treatment.

STUDY DESIGN

 This is a retrospective cohort study of term and late-preterm infants (≥35 weeks gestation) exposed to in utero opioids, born between September 2006 and August 2022, and required pharmacologic treatment for NOWS. Maternal and infant demographics were collected. Indicators of the severity of NOWS (duration of medical treatment (DOT), duration of hospitalization, maximum dose of opioid treatment, and use of secondary medications) were compared between male and female infants. Standard statistical tests and regression analysis were used to establish the differences in outcomes after accounting for confounders and baseline differences.

RESULTS

 Out of the 1,074 infants included in the study, 47.9% were female, and 52.1% were male. There was no significant difference in demographic and baseline clinical characteristics between groups except for anthropometry (birth weight, head circumference, and length) and Apgar score at 5 minutes. The median DOT (25 days [14, 39] vs. 23 days [13, 39], p = 0.57), length of hospital stay (31.5 days [20, 44] vs. 28 days [20, 44], p = 0.35), treatment with phenobarbital (24.7 vs. 26.3%, p = 0.56), and clonidine (3.9 vs. 3.8%, p = 0.9) were similar in both groups. The differences remained nonsignificant after adjusting for birth anthropometric measurements, gestational age, 5-minute Apgar score, small for gestational age status, and maternal exposure to benzodiazepines.

CONCLUSION

 In this cohort of neonates, sex-related differences were not identified to influence the severity of NOWS among those who required pharmacological treatment.

KEY POINTS

· Vulnerability to NOWS is multifactorial.. · The role of infant sex in the severity of NOWS is not concrete.. · We noted that sex did not impact NOWS severity in those treated..

Impact of sex, race, and social determinants of health on neonatal outcomes

Despite the global improvements in neonatal outcomes, mortality and morbidity rates among preterm infants are still unacceptably high. Therefore, it is crucial to thoroughly analyze the factors that affect these outcomes, including sex, race, and social determinants of health. By comprehending the influence of these factors, we can work towards reducing their impact and enhancing the quality of neonatal care. This review will summarize the available evidence on sex differences, racial differences, and social determinants of health related to neonates. This review will discuss sex differences in neonatal outcomes in part I and racial differences with social determinants of health in part II. Research has shown that sex differences begin to manifest in the early part of the pregnancy. Hence, we will explore this topic under two main categories: (1) Antenatal and (2) Postnatal sex differences. We will also discuss long-term outcome differences wherever the evidence is available. Multiple factors determine health outcomes during pregnancy and the newborn period. Apart from the genetic, biological, and sex-based differences that influence fetal and neonatal outcomes, racial and social factors influence the health and well-being of developing humans. Race categorizes humans based on shared physical or social qualities into groups generally considered distinct within a given society. Social determinants of health (SDOH) are the non-medical factors that influence health outcomes. These factors can include a person's living conditions, access to healthy food, education, employment status, income level, and social support. Understanding these factors is essential in developing strategies to improve overall health outcomes in communities.

Effects of prenatal opioid exposure on infant sympathetic and parasympathetic nervous system activity

Prenatal opioid exposure has been associated with developmental problems, including autonomic nervous system dysregulation. However, little is known about the effects of prenatal opioid exposure on the autonomic nervous system beyond the first days of life, particularly across both the parasympathetic and sympathetic branches, and when accounting for exposure to other substances. The present study examined the effects of prenatal exposure to opioid agonist therapy (OAT, e.g., methadone) and other opioids on infant autonomic nervous system activity at rest and in response to a social stressor (the Still-Face Paradigm) at six months among 86 infants varying in prenatal opioid and other substance exposure. Results indicated that OAT and other opioids have unique effects on the developing autonomic nervous system that may further depend on subtype (i.e., methadone versus buprenorphine) and timing in gestation. Results are discussed in the context of theoretical models of the developing stress response system.

Sex differences in neonatal outcomes following prenatal opioid exposure

The impact of the opioid epidemic on pregnant people and children is a growing public health crisis. Understanding how opioids affect the developing brain during pregnancy and postnatally remains a critical area of investigation. Biological sex plays a crucial role in all physiologic processes, with the potential for a significant impact on neonatal outcomes, including those infants with opioid exposure. Here, we aim to explore current literature on the effect of sex on neonatal outcomes following prenatal opioid exposure. Sex differences in adults with opioid use disorder have been well studied, including increased mortality among males and higher rates of psychiatric comorbidities and likelihood of relapse in females. However, such differences are not yet well understood in neonates. Emerging clinical data suggest sex-specific effects in infants with prenatal opioid exposure on the expression of genes related to feeding regulation and reward signaling pathways. Increased susceptibility to white matter injury has also been noted in female infants following prenatal opioid exposure. Understanding the impact of sex as a biological variable on neonatal outcomes following prenatal opioid exposure is paramount to improving the health and well-being of infants, children, and adults impacted by the opioid epidemic.

Impact of prenatal opioids on cardiac and autonomic development: systematic review and meta-analysis

Prenatal opioid exposure has recently risen four-fold with limited data on the developmental effects on neonatal physiology. The objective of this systematic review is to develop an association between prenatal opioid exposure and fetal and neonatal cardiac and autonomic development and function. The review was conducted in accordance with PRISMA Guidelines, and searches were conducted using PubMed, Embase, CINAHL, and Web of Science between May 25 and October 27, 2020. Twenty studies fit inclusion criteria, in four categories: (1) fetal cardiac outcomes, (2) neonatal cardiac outcomes, (3) noninvasive autonomic outcomes, and (4) clinical and behavioral measures. For the meta-analysis, three studies (total of 210 subjects) were included. Effect sizes were measured as the mean difference in fetal heart rate between opioid-exposed and non-exposed groups. Mothers with prenatal opioid use had a significantly lower fetal heart rate as compared to mothers without prenatal opioid use, requiring further studies to determine clinical significance.

A review of the genomics of neonatal abstinence syndrome

Neonatal abstinence syndrome (NAS) is a constellation of signs of withdrawal occurring after birth following in utero exposure to licit or illicit opioids. Despite significant research and public health efforts, NAS remains challenging to diagnose, predict, and manage due to highly variable expression. Biomarker discovery in the field of NAS is crucial for stratifying risk, allocating resources, monitoring longitudinal outcomes, and identifying novel therapeutics. There is considerable interest in identifying important genetic and epigenetic markers of NAS severity and outcome that can guide medical decision making, research efforts, and public policy. A number of recent studies have suggested that genetic and epigenetic changes are associated with NAS severity, including evidence of neurodevelopmental instability. This review will provide an overview of the role of genetics and epigenetics in short and longer-term NAS outcomes. We will also describe novel research efforts using polygenic risk scores for NAS risk stratification and salivary gene expression to understand neurobehavioral modulation. Finally, emerging research focused on neuroinflammation from prenatal opioid exposure may elucidate novel mechanisms that could lead to development of future novel therapeutics.

Neonatal outcomes of preterm infants with in-utero exposure to drugs of substance use: US national data

BACKGROUND

Infants exposed prenatally to drugs of substance use are at increased risk for seizures, strabismus, feeding difficulty, and neurodevelopmental delays. Exposed preterm infants may have additional morbidities related to prematurity. There is limited literature on national outcomes of preterm infants exposed to drugs of substance use. We aimed to evaluate the trends and neonatal outcomes of preterm infants born in the USA who were exposed in-utero to drugs of substance use.

METHODS

Retrospective cohort study of preterm live born (<37 weeks gestation) exposed in-utero to opioids, hallucinogens, or cocaine in the Healthcare Cost and Utilization Project database from 2002 to 2017. Neonatal outcomes were identified using international classification of diseases 9&10 codes.

RESULTS

Of the 54,469,720 live-born infants, 7.7% (4,194,816) were preterm, and 58 679 (1.4%) were exposed in-utero to maternal opioids/hallucinogens (n = 39,335) or cocaine (n = 19,344). There was a trend for increased exposure to opioids/hallucinogens (Z score = 76.14, p < 0.001) during the study period. Exposed preterm infants had significantly more neurological anomalies, intra-ventricular hemorrhage and periventricular leukomalacia (p < 0.001).

CONCLUSIONS

There was a trend for increased in-utero exposure to opioids and hallucinogens in the preterm infants in the USA. Exposed preterm infants had more neurological morbidities.

Developmental Pathways from Prenatal Substance Exposure to Reactive Aggression

Few studies have examined etiological pathways from prenatal substance exposure to adolescent reactive aggression. We tested a conceptual model that included hypothesized pathways from prenatal substance exposure to adolescent aggression via autonomic reactivity and violence exposure from infancy to early school age and maternal harshness across early childhood. The sample included 216 families (106 boys) who primarily self-identified as Black or Mixed Race. Results supported the hypothesized path from violence exposure across early childhood and early school age to school age autonomic reactivity and early adolescent reactive aggression. There was also a significant interaction effect of sympathetic and parasympathetic reactivity on adolescent reactive aggression, with sympathetic arousal and parasympathetic suppression at early school age associated with higher reactive relational and physical aggression in adolescence. Results emphasize the importance of early experiences and autonomic nervous system changes in contributing to the cascade of risk for reactive aggression in early adolescence.

Effects of an attachment-based intervention on autonomic regulation among opioid-exposed infants

Little is known about whether postnatal intervention enhances autonomic regulation among infants at risk for dysregulation due to prenatal opioid exposure. The present study evaluated the effects of modified Attachment Behavioral Catch-up (mABC) on autonomic regulation for opioid-exposed infants in a pilot randomized clinical trial. We hypothesized that, compared to a control intervention (modified Developmental Education for Families [mDEF]), mABC would be associated with higher resting respiratory sinus arrhythmia (RSA) and pre-ejection period (PEP) as well as greater reactivity to and recovery from a social stressor (Still-Face Paradigm). Pregnant or peripartum women receiving opioid agonist therapy (61 mothers of 64 infants; final N = 36 infants) were randomly assigned to mABC or mDEF, 12-session home visiting programs beginning in the third trimester; mABC targets sensitive parenting, and mDEF targets cognitive and motor development. mABC was associated with significantly greater RSA reactivity and marginally greater PEP reactivity. In models accommodating missing data, mABC was additionally associated with significantly greater RSA recovery. In sensitivity analyses removing siblings, mABC predicted significantly enhanced PEP reactivity. Overall, in these preliminary analyses, mABC was associated with healthier autonomic regulation during a social stressor than mDEF. Thus, mABC may be a promising strategy to promote autonomic regulation among opioid-exposed infants through parenting intervention.

Neonatal heart rate variability: a contemporary scoping review of analysis methods and clinical applications

BACKGROUND

Neonatal heart rate variability (HRV) is widely used as a research tool. However, HRV calculation methods are highly variable making it difficult for comparisons between studies.

OBJECTIVES

To describe the different types of investigations where neonatal HRV was used, study characteristics, and types of analyses performed.

ELIGIBILITY CRITERIA

Human neonates ≤1 month of corrected age.

SOURCES OF EVIDENCE

A protocol and search strategy of the literature was developed in collaboration with the McGill University Health Center's librarians and articles were obtained from searches in the Biosis, Cochrane, Embase, Medline and Web of Science databases published between 1 January 2000 and 1 July 2020.

CHARTING METHODS

A single reviewer screened for eligibility and data were extracted from the included articles. Information collected included the study characteristics and population, type of HRV analysis used (time domain, frequency domain, non-linear, heart rate characteristics (HRC) parameters) and clinical applications (physiological and pathological conditions, responses to various stimuli and outcome prediction).

RESULTS

Of the 286 articles included, 171 (60%) were small single centre studies (sample size <50) performed on term infants (n=136). There were 138 different types of investigations reported: physiological investigations (n=162), responses to various stimuli (n=136), pathological conditions (n=109) and outcome predictor (n=30). Frequency domain analyses were used in 210 articles (73%), followed by time domain (n=139), non-linear methods (n=74) or HRC analyses (n=25). Additionally, over 60 different measures of HRV were reported; in the frequency domain analyses alone there were 29 different ranges used for the low frequency band and 46 for the high frequency band.

CONCLUSIONS

Neonatal HRV has been used in diverse types of investigations with significant lack of consistency in analysis methods applied. Specific guidelines for HRV analyses in neonates are needed to allow for comparisons between studies.

Neonatal Outcomes after Combined Opioid and Nicotine Exposure in Utero: A Scoping Review

BACKGROUND

The majority of women who are pregnant with opioid use disorder (OUD) also smoke tobacco but are rarely offered tobacco cessation counseling. While the effects of exposure to opioids and nicotine in utero are well-understood separately, understanding the impact of the combined exposure to these substances on neonatal outcomes is lacking.

METHODS

A scoping review was conducted using PubMed and Scopus databases for studies addressing the combined exposure to opioids and nicotine during pregnancy published between 1 January 1980 and 9 July 2019. A total of 29 papers met the eligibility criteria for inclusion, with nine being identified as clinical trials (three from the MOTHER study) and two as secondary data analysis of clinical trial data.

RESULTS

Neonatal outcomes for infants who had a combined exposure to opioids and nicotine in utero indicated a reduction in birth weight and birth length. Findings in infants exposed to both nicotine and opioids were mixed with regard to the duration of neonatal abstinence syndrome (NAS), the likelihood of treatment for NAS, doses of medicine used to treat NAS, and NAS scores when compared with infants who had opioid exposure without nicotine.

CONCLUSIONS

The combined exposure to nicotine and opioids during pregnancy may lead to a reduction in neonatal birth weight and birth length and more severe NAS signs, compared with opioid use alone, but more research is necessary to identify the minimum dosage and length of nicotine exposure to accurately predict these outcomes.

Reconceptualizing non-pharmacologic approaches to Neonatal Abstinence Syndrome (NAS) and Neonatal Opioid Withdrawal Syndrome (NOWS): A theoretical and evidence-based approach

Discussions about non-pharmacologic interventions for Neonatal Abstinence Syndrome and Neonatal Opioid Withdrawal Syndrome (NAS/NOWS) have been minor compared with wider attention to pharmacologic treatments. Although historically under-recognized, non-pharmacologic interventions are of paramount importance for all substance-exposed infants and remain as a first line therapy for the care of infants affected by NAS. Here we examine the role of non-pharmacologic interventions for NAS/NOWS by incorporating theoretical perspectives from different disciplines that inform the importance of individualized assessment of the mother-caregiver/infant dyad and interventions that involve both individuals. NAS/NOWS is a complex, highly individualized constellation of signs/symptoms that vary widely in onset, duration, severity, expression, responses to treatment and influence on long-term outcomes. NAS/NOWS often occurs in infants with multiple prenatal/postnatal factors that can compromise neurobiological self-regulatory functioning. We propose to rethink some of the long-held assumptions, beliefs, and paradigms about non-pharmacologic care of the infant with NAS/NOWS, which is provided as non-specific or as "bundled" in current approaches. This paper is Part I of a two-part series on re-conceptualizing non-pharmacologic care for NAS/NOWS as individualized treatment of the dyad. Here, we set the foundation for a new treatment approach grounded in developmental theory and evidence-based observations of infant neurobiology and neurodevelopment. In Part II, we provide actionable, individually tailored evaluations and approaches to non-pharmacologic NAS/NOWS treatment based on measurable domains of infant neurobehavioral functioning.

Transcutaneous Auricular Neurostimulation (tAN): A Novel Adjuvant Treatment in Neonatal Opioid Withdrawal Syndrome

Maternal opioid use during pregnancy is a growing national problem and can lead to newborns developing neonatal opioid withdrawal syndrome (NOWS) soon after birth. Recent data demonstrates that nearly every 15 min a baby is born in the United States suffering from NOWS. The primary treatment for NOWS is opioid replacement therapy, commonly oral morphine, which has neurotoxic effects on the developing brain. There is an urgent need for non-opioid treatments for NOWS. Transcutaneous auricular neurostimulation (tAN), a novel and non-invasive form of electrostimulation, may serve as a promising alternative to morphine. tAN is delivered via a multichannel earpiece electrode worn on and around the left ear, targeting two cranial nerves—the vagus and trigeminal nerves. Prior research suggests that auricular neurostimulation exerts an anxiolytic effect on the body by releasing endogenous opioids and reduces withdrawal symptoms in adults actively withdrawing from opioids. In this first-in-human prospective, open-label trial, we investigated tAN as an adjuvant to morphine therapy in eight infants >33 weeks gestational age suffering from NOWS and receiving oral morphine treatment. Infants received tAN for 30 min 1 h before receiving a morphine dose. tAN was delivered at 0.1 mA below perception intensity at two different nerve targets on the ear: Region 1, the auricular branch of the vagus nerve; and Region 2, the auriculotemporal nerve. tAN was delivered up to four times daily for a maximum of 12 days. The primary outcome measures were safety [heart rate monitoring, Neonatal Infant Pain Scale (NIPS), and skin irritation] and morphine length of treatment (LOT). tAN was well-tolerated and resulted in no unanticipated adverse events. Comparing to the national average of 23 days, the average oral morphine LOT was 13.3 days (median 9 days) and the average LOT after tAN initiation was 7 days (median 6 days). These preliminary data suggest that tAN is safe and may serve as a promising alternative adjuvant for treating NOWS and reducing the amount of time an infant receives oral morphine.

Study design and rationale for a randomized controlled trial to assess effectiveness of stochastic vibrotactile mattress stimulation versus standard non-oscillating crib mattress for treating hospitalized opioid-exposed newborns

The incidence of Neonatal Abstinence Syndrome (NAS) continues to rise and there remains a critical need to develop non-pharmacological interventions for managing opioid withdrawal in newborns. Objective physiologic markers of opioid withdrawal in the newborn remain elusive. Optimal treatment strategies for improving short-term clinical outcomes and promoting healthy neurobehavioral development have yet to be defined. This dual-site randomized controlled trial (NCT02801331) is designed to evaluate the therapeutic efficacy of stochastic vibrotactile stimulation (SVS) for reducing withdrawal symptoms, pharmacological treatment, and length of hospitalization, and for improving developmental outcomes in opioid-exposed neonates. Hospitalized newborns (n = 230) receiving standard clinical care for prenatal opioid exposure will be randomly assigned within 48-hours of birth to a crib with either: 1) Intervention (SVS) mattress: specially-constructed SVS crib mattress that delivers gentle vibrations (30-60 Hz, ~12 μm RMS surface displacement) at 3-hr intervals; or 2) Control mattress (treatment as usual; TAU): non-oscillating hospital-crib mattress. Infants will be studied throughout their hospitalization and post discharge to 14-months of age. The study will compare clinical measures (i.e., withdrawal scores, cumulative dose and duration of medications, velocity of weight gain) and characteristic progression of physiologic activity (i.e., limb movement, cardio-respiratory, temperature, blood-oxygenation) throughout hospitalization between opioid-exposed infants who receive SVS and those who receive TAU. Developmental outcomes (i.e., physical, social, emotional and cognitive) within the first year of life will be evaluated between the two study groups. Findings from this randomized controlled trial will determine whether SVS reduces in-hospital severity of NAS, improves physiologic function, and promotes healthy development.

Exposures influencing the developing central autonomic nervous system

Autonomic nervous system function is critical for transition from in-utero to ex-utero life and is associated with neurodevelopmental and neuropsychiatric outcomes later in life. Adverse prenatal and neonatal conditions and exposures can impair or alter ANS development and, as a result, may also impact long-term neurodevelopmental outcomes. The objective of this article is to provide a broad overview of the impact of factors that are known to influence autonomic development during the fetal and early neonatal period, including maternal mood and stress during and after pregnancy, fetal growth restriction, congenital heart disease, toxic exposures, and preterm birth. We touch briefly on the typical development of the ANS, then delve into both in-utero and ex-utero maternal and fetal factors that may impact developmental trajectory of the ANS and, thus, have implications in transition and in long-term developmental outcomes. While many types of exposures and conditions have been shown to impact development of the autonomic nervous system, there is still much to be learned about the mechanisms underlying these influences. In the future, more advanced neuromonitoring tools will be required to better understand autonomic development and its influence on long-term neurodevelopmental and neuropsychological function, especially during the fetal period.

"Babywearing" in the NICU: An Intervention for Infants With Neonatal Abstinence Syndrome

BACKGROUND

The US opioid epidemic has resulted in an increase of infants at risk for developing neonatal abstinence syndrome (NAS). Traditionally, treatment has consisted of pharmacological interventions to reduce symptoms of withdrawal. However, nonpharmacological interventions (eg, skin-to-skin contact, holding) can also be effective in managing the distress associated with NAS.

PURPOSE

The purpose of this study was to examine whether infant carrying or "babywearing" (ie, holding an infant on one's body using cloth) can reduce distress associated with NAS among infants and caregivers.

METHODS

Heart rate was measured in infants and adults (parents vs other adults) in a neonatal intensive care unit (NICU) pre- (no touching), mid- (20 minutes into being worn in a carrier), and post-babywearing (5 minutes later).

RESULTS

Using a 3-level hierarchical linear model at 3 time points (pre, mid, and post), we found that babywearing decreased infant and caregiver heart rates. Across a 30-minute period, heart rates of infants worn by parents decreased by 15 beats per minute (bpm) compared with 5.5 bpm for infants worn by an unfamiliar adult, and those of adults decreased by 7 bpm (parents) and nearly 3 bpm (unfamiliar adult).

IMPLICATIONS FOR PRACTICE

Results from this study suggest that babywearing is a noninvasive and accessible intervention that can provide comfort for infants diagnosed with NAS. Babywearing can be inexpensive, support parenting, and be done by nonparent caregivers (eg, nurses, volunteers).

IMPLICATIONS FOR RESEARCH

Close physical contact, by way of babywearing, may improve outcomes in infants with NAS in NICUs and possibly reduce the need for pharmacological treatment.See the video abstract for a digital summary of the study. VIDEO ABSTRACT AVAILABLE AT:.

Neonatal Abstinence Syndrome Severity Index Predicts 18-Month Neurodevelopmental Outcome in Neonates Randomized to Morphine or Methadone

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.

Factors Associated With the Need for Pharmacological Management of Neonatal Opioid Withdrawal Syndrome

BACKGROUND

Neonatal opioid withdrawal syndrome (NOWS) is a significant and growing health problem that affects more than 23,000 infants annually, with an estimated hospital cost of more than $720 million.

PURPOSE

The purpose of this study was to examine factors associated with the need to initiate medication for the treatment of NOWS.

METHODS

A retrospective review of medical records was conducted of 204 infants born to mothers who used opioids during pregnancy from April 2011 to September 2017. Associations between maternal, infant, and environmental factors and the need for neonatal pharmacological management were examined using χ, t tests, and regression analysis.

RESULTS

Of 204 neonates exposed to opioids prenatally, 121 (59%) developed symptoms of NOWS, requiring treatment with morphine. Neonates requiring morphine had significantly higher gestational ages (37.7 weeks vs 36.4 weeks; P < .001), and mothers were present at the neonate's bedside for a lower proportion of their total hospital stay (57% vs 74% of days; P < .001). Maternal factors associated with the need for neonatal medication treatment included the mother's reason for opioid use (P = .014), primary type of opioid used (P < .001), tobacco use (P = .023), and use of benzodiazepines (P = .003).

IMPLICATIONS FOR PRACTICE

This research provides information regarding the proportion of infants exposed to opioids prenatally who develop NOWS that requires treatment, as well as maternal, infant, and environmental factors associated with the need for neonatal medication use.

IMPLICATIONS FOR RESEARCH

Future research is needed to examine these relationships prospectively in a larger and more diverse sample.

Developmental Outcomes of Infants Adopted from Foster Care: Predictive Associations from Perinatal and Preplacement Risk Factors

Infants adopted domestically from foster care often present with prenatal substance exposure and risky birth outcomes such as prematurity and low birth weight. Because few longitudinal studies of foster-adoptive infants exist, it is unclear how these preplacement risk factors influence development over time. The present study examined associations between perinatal risk factors and developmental outcomes among an ethnically/racially-diverse sample of 97 infants in foster-care (56% boys) placed into adoptive homes at ages 0-19 months. Relative to population-norms, foster-adoptive infants showed comparable cognitive but lower language and motor functioning at baseline and one-year follow-up. Age-adjusted language scores significantly improved one year following placement, consistent with a developmental "catch-up" effect. Low birth weight uniquely predicted lower language scores at baseline, but this association was no longer significant at follow-up. Prenatal substance exposure was associated with lower baseline cognitive scores, but only for infants placed after six months of age. In contrast, infants with low birth weight and later placement age (>12 months) showed the most accelerated motor development. Sex differences emerged at follow-up when predicting motor and language outcomes, suggesting potential sex-specific pathways of risk. Overall, results support adoption as an early intervention that may buffer vulnerability to perinatal risk on development.

Gender Differences in the Outcome of Offspring Prenatally Exposed to Drugs of Abuse

Despite great efforts to warn pregnant women that drugs of abuse impact development of the embryo and the fetus, the use of legal and illegal drugs by childbearing women is still a major public health concern. In parallel with well-established teratogenic effects elicited by some drugs of abuse, epidemiological studies show that certain psychoactive substances do not induce birth defects but lead to subtle neurobehavioral alterations in the offspring that manifest as early as during infancy. Although gender differences in offspring susceptibility have not been fully investigated, a number of longitudinal studies indicate that male and female progeny exposed in utero to drugs of abuse show different vulnerabilities to deleterious effects of these substances in cognitive, executive, and behavioral domains. Here, we briefly review the existing literature focusing on gender differences in the neurobehavioral consequences of maternal exposure to drugs of abuse. Overall, the data strongly indicate that male exposed progeny are more susceptible than female to dysfunctions in cognitive processing and emotional regulation. However, insights into the mechanisms determining this natural phenomenon are not currently available. Our analysis prompts future investigations to implement clinical studies including the influence of gender/sex as a biological variable in the outcome of offspring prenatally exposed to drugs of abuse.

Salivary cortisol levels as a biomarker for severity of withdrawal in opioid-exposed newborns

BACKGROUND

Scoring tools used to quantify withdrawal in infants with neonatal abstinence syndrome (NAS) are often confounded by subjective measurements. This study assessed salivary cortisol as an objective biomarker of withdrawal severity in opioid-exposed newborns.

METHODS

A prospective study was conducted in 25 full-term opioid-exposed newborns monitored for NAS. Morning and evening salivary cortisol levels were collected starting within 48 h post birth until initiation of pharmacologic treatment for withdrawal (Pre-Treatment) or when the infant was discharged without pharmacotherapy (No Treatment).

RESULTS

Cortisol levels in the Pre-Treatment group (n = 11) were significantly higher within the first week of life (median 1.74 µg/dl) than in the No Treatment group (n = 11; median 0.72 µg/dl; P = 0.003); three infants had inadequate saliva volume for cortisol assay. Cortisol significantly decreased after 72 h post birth among infants discharged without pharmacotherapy (≤72 h median 1.25 µg/dl; ≥72 h median 0.58 µg/dl; P = 0.022), whereas cortisol remained elevated for infants subsequently treated for severity of withdrawal. No cortisol circadian rhythm was observed for either group.

CONCLUSIONS

Salivary cortisol in opioid-exposed newborns may provide an index of stress and help identify infants who will have more severe clinical presentation of NAS. Such a biomarker would allow risk stratification for early treatment and discharge decisions.

Maternal Pregnancy Diet Quality Is Directly Associated with Autonomic Nervous System Function in 6-Month-Old Offspring

BACKGROUND

Many pregnant women are consuming diets of poor overall quality. Although many studies have linked poor prenatal diet quality to an increased risk of specific diseases in offspring, it is not known if exposure to poor prenatal diet affects core neurophysiological regulatory systems in offspring known to lie upstream of multiple diseases.

OBJECTIVE

We aimed to examine the association between prenatal diet quality and autonomic nervous system (ANS) function in infants at 6 mo of age.

METHODS

Data from 400 women (aged >18 y, with uncomplicated pregnancies) and their infants participating in the Maternal-Infant Research on Environmental Chemicals-Infant Development cohort were used to investigate links between prenatal diet quality and infant ANS function at 6 mo of age. Prenatal diet quality was assessed using the Healthy Eating Index (2010), calculated from a validated FFQ completed by women during the first trimester. Infant ANS function was measured using 2 assessments of heart rate variability (HRV) including root mean square of successive differences (RMSSD) and SD of N-N intervals (SDNN). Associations were analyzed before and after adjustment for socioeconomic status, maternal depression symptoms, maternal cardiometabolic dysfunction, breastfeeding, and prenatal smoking.

RESULTS

Poorer prenatal diet quality was associated with lower infant HRV assessed using RMSSD (B: 0.07; 95% CI: 0.01, 0.13; R2 = 0.013) and SDNN (B: 0.18; 95% CI: 0.02, 0.35; R2 = 0.011). These associations remained significant after adjustment for confounding variables [RMSSD: B: 0.09; 95% CI: 0.003, 0.18; squared semipartial correlation (sp2) = 0.14 and SDNN B: 0.24; 95% CI: 0.0, 0.49; sp2 = 0.13].

CONCLUSIONS

In a large cohort study, poorer prenatal diet quality was associated with lower offspring HRV, a marker of decreased capacity of the ANS to respond adaptively to challenge. Therefore, poor prenatal diet may play a significant role in the programming of multiple organ systems and could increase general susceptibility to disease in offspring.

Neonatal Abstinence Syndrome: Review of Epidemiology, Care Models, and Current Understanding of Outcomes

The incidence of neonatal abstinence syndrome owing to prenatal opioid exposure has grown rapidly in recent decades and it disproportionately affects rural, non-white, and public insurance-dependent populations. Treatment consists of pharmacologic and nonpharmacologic interventions with wide variability in approaches across the United States. Standardizing clinical assessment, minimizing unnecessary interruptions, and prioritizing nonpharmacologic and family-centered care seems to improve hospital outcomes. Neonatal abstinence syndrome may have long-term developmental and biological effects, but understanding is limited owing in part confounding biosocial factors. Early intervention and longitudinal support of the infant and family promote better outcomes.

Risk Factors Associated with the Occurrence of Neonatal Opioid Withdrawal Syndrome: A Review

In a number of countries, the prevalence of neonatal opioid withdrawal syndrome (NOWS) is increasing. While NOWS is ultimately the result of opioid exposure in utero, a wide range of risk factors have been associated with the prevalence of NOWS, extending beyond just drug exposure. This article reviews the available literature on factors associated with the incidence of NOWS in opioid-exposed neonates. A range of risk factors have been associated with NOWS, including features of neonatal drug exposure, maternal and neonatal characteristics, aspects of labor and delivery, and genetics. Increased length of gestation and higher birth weight were consistently associated with an increased risk of NOWS, while breast feeding and 'rooming-in' were associated with a reduced risk of NOWS. Additionally, several genetic factors have also been associated with NOWS severity. There is conflicting evidence on the association between NOWS and other risk factors including opioid dose, neonate sex, and the use of some medications during pregnancy. This may be in part attributable to differences in how NOWS is diagnosed and the variety of methodologies across studies. While a large number of risk factors associated with NOWS are non-modifiable, encouraging pregnant women to reduce other drug use (including smoking), breast feed their child, and the judicious use of medications during pregnancy may help reduce the prevalence of NOWS. The presence or absence of NOWS in an opioid-exposed neonate is associated with a wide range of factors. Some of these modifiable risk factors may be potential targets for the primary prevention of NOWS.

Drivers of Hospital Length of Stay in Medicaid and Commercially Insured Mother-Infant Pairs With a Diagnosis of Neonatal Abstinence Syndrome

BACKGROUND

The occurrence of neonatal abstinence syndrome (NAS) mirrors the growing opioid epidemic in the United States. As Medicaid covers a majority of cases, the commercially insured population has largely been ignored for NAS risk.

OBJECTIVE

The objective of this study was to examine Medicaid and commercially insured mother-infant pairs to determine demographic and clinical characteristics associated with NAS length of stay (LOS).

RESEARCH DESIGN

This observational, descriptive case-series study utilized administrative claims from HealthCore Integrated Research Database to measure maternal characteristics for 6 months before delivery, and neonatal characteristics and health care service utilization for 3 months after NAS diagnosis. Bootstrapped regressions were used to model LOS.

RESULTS

The sample included 1807 mother-infant pairs. Most infants (79%) had Medicaid coverage (Medicaid: N=1419; Commercial: N=388). Although all infants had NAS, Medicaid-insured mothers had more prevalent drug abuse (70.8% vs. 41.0%; P<0.0001), but fewer used prescription opioids (45.3% vs. 60.8%; P<0.0001) compared with commercially insured mothers. Commercially insured infants were sicker, with a higher prevalence of complex chronic conditions, and yet Medicaid-insured infants were admitted to neonatal intensive care unit at a much higher rate (91.1% vs. 78.9%; P<0.0001). After adjustment, neonatal intensive care unit admission (+6.7 d, 95% confidence interval: 4.5-9.3) and chronic complex conditions (+5.2 d, 95% confidence interval: 3.8-6.6) contributed most to LOS.

CONCLUSION

A re-evaluation of obstetrical management towards a focus on the history of possible opioid and substance use regardless of insurance type and demographic background might inform efforts to reduce LOS.

The role of mother-infant bond in neonatal abstinence syndrome (NAS) management

The opioid crisis affects pregnant women and their infants. In the past two decades, the number of infants born with neonatal abstinence syndrome (NAS) has quadrupled causing the cost of healthcare expenditures to climb sharply. Pharmacological and non-pharmacological approaches are recommended for the management of NAS. Despite the attention NAS has recently received, treatment recommendations are limited to the hospital setting with much less focus on discharge planning. Additionally, the literature on NAS management does not consider research promoting mother-infant attachment. Recently, more emphasis has been placed on taking a holistic approach to NAS management. However, scholarly writings and research in this area are scarce. This article provides a review of current literature on NAS management and attachment-based interventions. Recommendations for practice and future research focused on holistic, non-pharmacological approaches to NAS management are provided.

The Possibility of Early Discharge for Newborns Being Monitored for Neonatal Abstinence Syndrome Based on Modified Finnegan Score Distributions

We tested the hypothesis that Modified Finnegan Neonatal Scoring System (MFNSS) scores can guide early discharge at 72 hours for newborns at risk for neonatal abstinence syndrome (NAS). A retrospective cohort study with a primary outcome of early discharge of newborns at risk for NAS using mean MFNSS scores recorded before pharmacologic treatment was performed. Quantile regression was used to develop percentile curves of mean MFNSS scores. A total of 202 term newborns at risk for NAS with 5066 mean MFNSS scores recorded before pharmacologic treatment were studied. Sixty-eight of 121 (56%) newborns not treated at 72 hours had mean MFNSS scores <50th percentile and only 1 was ultimately treated (1.5%, 95% confidence interval: 0% to 8%). No newborns with mean MFNSS scores <25th percentile at 72 hours were treated. Newborns at risk for NAS with mean MFNSS scores <50th percentile can be safely discharged by 72 hours if families can assure close outpatient follow-up.

In Utero Exposure to Norbuprenorphine, a Major Metabolite of Buprenorphine, Induces Fetal Opioid Dependence and Leads to Neonatal Opioid Withdrawal Syndrome

Buprenorphine is the preferred treatment of opioid use disorder during pregnancy but can cause fetal opioid dependence and neonatal opioid withdrawal syndrome (NOWS). Notably, withdrawal severity is independent of maternal buprenorphine dose, suggesting that interindividual variance in pharmacokinetics may influence risk and severity of NOWS. Using a rat model of NOWS, we tested the hypothesis that clinically relevant doses of the active metabolite norbuprenorphine (NorBUP) can induce in utero opioid dependence, manifested as naltrexone-precipitated withdrawal signs in the neonate. Pregnant Long-Evans rats were implanted with 14-day osmotic minipumps containing vehicle, morphine (positive control), or NorBUP (0.3-10 mg/kg per day) on gestation day 9. By 12 hours post-delivery, an intraperitoneal injection of the opioid antagonist naltrexone (1 or 10 mg/kg) or saline was administered to pups. Precipitated withdrawal signs were graded by raters blinded to treatment conditions. In a separate group, NorBUP concentrations in maternal and fetal blood and brain on gestation day 20 were determined by liquid chromatography-tandem mass spectrometry. Steady-state maternal blood concentrations of NorBUP in dams infused with 1 or 3 mg/kg per day were comparable to values reported in pregnant humans treated with buprenorphine (1.0 and 9.6 ng/ml, respectively), suggesting a clinically relevant dosing regimen. At these doses, NorBUP increased withdrawal severity in the neonate as shown by an evaluation of 10 withdrawal indicators. These findings support the possibility that NorBUP contributes to fetal opioid dependence and NOWS following maternal buprenorphine treatment during pregnancy.

Beyond the Finnegan scoring system: Novel assessment and diagnostic techniques for the opioid-exposed infant

Infants with in-utero opioid exposure are most commonly assessed using the Finnegan Neonatal Abstinence Scoring System (FNASS) or a modified version of that tool. Traditionally, the purpose of these tools has been to characterize the extent of withdrawal signs to guide the pharmacologic treatment for infants with neonatal opioid withdrawal syndrome (NOWS). In the past decade however, in response to some of the limitations of the FNASS tool, there has been an increasing emphasis on developing novel assessment tools not based on the FNASS in addition to the promotion of non-pharmacologic treatment options as the first line treatment for infants with opioid exposure. Additionally, several prediction tools that may be useful in determining which patients are at high or low risk for receiving pharmacologic therapy have been developed. In this review, we will evaluate the clinical utility of these novel tools and will consider new avenues for future research.

Autonomic nervous system functioning assessed during the Still-Face Paradigm: A meta-analysis and systematic review of methods, approach and findings

Animal and human research suggests that the development of the autonomic nervous system (ANS) is particularly sensitive to early parenting experiences. The Still-Face Paradigm (SFP), one of the most widely used measures to assess infant reactivity and emotional competence, evokes infant self-regulatory responses to parental interaction and disengagement. This systematic review of 33 peer-reviewed studies identifies patterns of parasympathetic (PNS) and sympathetic (SNS) nervous system activity demonstrated by infants under one year of age during the SFP and describes findings within the context of sample demographic characteristics, study methodologies, and analyses conducted. A meta-analysis of a subset of 14 studies with sufficient available respiratory sinus arrhythmia (RSA) data examined whether the SFP reliably elicited PNS withdrawal (RSA decrease) during parental disengagement or PNS recovery (RSA increase) during reunion, and whether results differed by socioeconomic status (SES). Across SES, the meta-analysis confirmed that RSA decreased during the still-face episode and increased during reunion. When studies were stratified by SES, low-SES or high-risk groups also showed RSA decreases during the still face episode but failed to show an increase in RSA during reunion. Few studies have examined SNS activity during the SFP to date, preventing conclusions in that domain. The review also identified multiple qualifications to patterns of SFP ANS findings, including those that differed by ethnicity, infant sex, parental sensitivity, and genetics. Strengths and weaknesses in the extant research that may explain some of the variation in findings across the literature are also discussed, and suggestions for strengthening future research are provided.

Association of Rooming-in With Outcomes for Neonatal Abstinence Syndrome: A Systematic Review and Meta-analysis

IMPORTANCE

Rising incidence of neonatal abstinence syndrome (NAS) is straining perinatal care systems. Newborns with NAS traditionally receive care in neonatal intensive care units (NICUs), but rooming-in with mother and family has been proposed to reduce the use of pharmacotherapy, length of stay (LOS), and cost.

OBJECTIVE

To systematically review and meta-analyze if rooming-in is associated with improved outcomes for newborns with NAS.

DATA SOURCES

MEDLINE, CINAHL, The Cochrane Library, and clinicaltrials.gov were searched from inception through June 25, 2017.

STUDY SELECTION

This investigation included randomized clinical trials, cohort studies, quasi-experimental studies, and before-and-after quality improvement investigations comparing rooming-in vs standard NICU care for newborns with NAS.

DATA EXTRACTION AND SYNTHESIS

Two independent investigators reviewed studies for inclusion. A random-effects model was used to pool dichotomous outcomes using risk ratio (RR) and 95% CI. The study evaluated continuous outcomes using weighted mean difference (WMD) and 95% CI.

MAIN OUTCOMES AND MEASURES

The primary outcome was newborn treatment with pharmacotherapy. Secondary outcomes included LOS, inpatient cost, and harms from treatment, including in-hospital adverse events and readmission rates.

RESULTS

Of 413 publications, 6 studies (n = 549 [number of patients]) met inclusion criteria. In meta-analysis of 6 studies, there was consistent evidence that rooming-in is preferable to NICU care for reducing both the use of pharmacotherapy (RR, 0.37; 95% CI, 0.19-0.71; I2 = 85%) and LOS (WMD, -10.41 days; 95% CI, -16.84 to -3.98 days; I2 = 91%). Sensitivity analysis resolved the heterogeneity for the use of pharmacotherapy, significantly favoring rooming-in (RR, 0.32; 95% CI, 0.18-0.57; I2 = 13%). Three studies reported that inpatient costs were lower with rooming-in; however, significant heterogeneity precluded quantitative analysis. Qualitative analysis favored rooming-in over NICU care for increasing breastfeeding rates and discharge home in familial custody, but few studies reported on these outcomes. Rooming-in was not associated with higher rates of readmission or in-hospital adverse events.

CONCLUSIONS AND RELEVANCE

Opioid-exposed newborns rooming-in with mother or other family members appear to be significantly less likely to be treated with pharmacotherapy and have substantial reductions in LOS compared with those cared for in NICUs. Rooming-in should be recommended as a preferred inpatient care model for NAS.

A Quality Improvement Initiative to Increase Scoring Consistency and Accuracy of the Finnegan Tool: Challenges in Obtaining Reliable Assessments of Drug Withdrawal in Neonatal Abstinence Syndrome

BACKGROUND

Current practice for diagnosing neonatal abstinence syndrome and guiding pharmacological management of neonatal drug withdrawal is dependent on nursing assessments and repeated evaluation of clinical signs.

PURPOSE

This single-center quality improvement initiative was designed to improve accuracy and consistency of Finnegan scores among neonatal nurses.

METHODS

One-hundred seventy neonatal nurses participated in a single-session withdrawal-assessment program that incorporated education, scoring guidelines, and a restructured Finnegan scale. Nurses scored a standardized video-recorded infant presenting with opioid withdrawal before and after training.

RESULTS

Nearly twice as many nurses scored at target (Finnegan score of 8) posttraining (34.7%; mean error = 0.559, SD = 1.4) compared with pretraining (18.8%; mean error = 1.31, SD = 1.95; Wilcoxon, P < .001). Finnegan scores were significantly higher than the target score pretraining (mean = 9.31, SD = 1.95) compared with posttraining (mean = 8.56, SD = 1.40, Wilcoxon P < .001); follow-up assessments reverted to pretraining levels (mean = 9.16, SD = 1.8). Score dispersion was greater pretraining (variance 3.80) compared with posttraining (variance 1.96; Kendall's Coefficient, P < .001) largely due to score disparity among central nervous system symptomology.

IMPLICATIONS FOR PRACTICE

Education, clinical guidelines, and a restructured scoring tool increased consistency and accuracy of infant withdrawal-assessments among neonatal nurses. However, more than 60% of nurses did not assess withdrawal to the target score immediately following the training period and improvements did not persist over time.

IMPLICATIONS FOR RESEARCH

This study highlights the need for more objective tools to quantify withdrawal severity given that assessments are the primary driver of pharmacological management in neonatal drug withdrawal.Video Abstract available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx.

Male Sex Associated With Increased Risk of Neonatal Abstinence Syndrome

BACKGROUND

Neonatal abstinence syndrome (NAS) is a postnatal opioid withdrawal syndrome. Factors associated with development of the syndrome are poorly understood; however, infant sex may influence the risk of NAS. Our objective was to determine if infant sex was associated with the development or severity of the syndrome in a large population-based cohort.

METHODS

This retrospective cohort study used vital statistics and prescription, outpatient, and inpatient administrative data for mothers and infants enrolled in the Tennessee Medicaid program between 2009 and 2011. Multivariable logistic regression models were used to evaluate the association between male sex and diagnosis of NAS, accounting for potential demographic and clinical confounders. NAS severity, as evidenced by hospital length of stay, was modeled by using negative binomial regression.

RESULTS

Of 102 695 infants, 927 infants were diagnosed with NAS (484 male subjects and 443 female subjects). Adjustments were made for the following: maternal age, race, and education; maternal hepatitis C infection, anxiety, or depression; in utero exposure to selective serotonin reuptake inhibitors and cigarettes; infant birth weight, small for gestational age, and year; and the interaction between opioid type and opioid amount. Male infants were more likely than female infants to be diagnosed with NAS (adjusted odds ratio, 1.18 [95% confidence interval, 1.05-1.33]) and NAS requiring treatment (adjusted odds ratio, 1.24 [95% confidence interval, 1.04-1.47]). However, there was no sex-based difference in severity for those diagnosed with NAS.

CONCLUSIONS

Treatment of NAS should be tailored to an infant's individual risk for the syndrome. Clinicians should be mindful that male sex is an important risk factor in the diagnosis of NAS.

Vibrotactile stimulation: A non-pharmacological intervention for opioid-exposed newborns

Objective

To examine the therapeutic potential of stochastic vibrotactile stimulation (SVS) as a complementary non-pharmacological intervention for withdrawal in opioid-exposed newborns.

Study design

A prospective, within-subjects single-center study was conducted in 26 opioid-exposed newborns (>37 weeks; 16 male) hospitalized since birth and treated pharmacologically for Neonatal Abstinence Syndrome. A specially-constructed mattress delivered low-level SVS (30-60Hz, 10–12μm RMS), alternated in 30-min intervals between continuous vibration (ON) and no vibration (OFF) over a 6–8 hr session. Movement activity, heart rate, respiratory rate, axillary temperature and blood-oxygen saturation were calculated separately for ON and OFF.

Results

There was a 35% reduction in movement activity with SVS (p<0.001), with significantly fewer movement periods >30 sec duration for ON than OFF (p = 0.003). Incidents of tachypneic breaths and tachycardic heart beats were each significantly reduced with SVS, whereas incidents of eupneic breaths and eucardic heart beats each significantly increased with SVS (p<0.03). Infants maintained body temperature and arterial-blood oxygen level independent of stimulation condition.

Conclusions

SVS reduced hyperirritability and pathophysiological instabilities commonly observed in pharmacologically-managed opioid-exposed newborns. SVS may provide an effective complementary therapeutic intervention for improving autonomic function in newborns with Neonatal Abstinence Syndrome.

Neonatal Abstinence Syndrome: Presentation and Treatment Considerations

The increase in opioid use among the general population is reflected in pregnant women and neonatal abstinence syndrome (NAS) statistics. This increase has produced an unprecedented focus on NAS from both the political-judicial sphere and the medical community. Under the banner of fetal protection, judges and prosecutors have implemented punitive approaches against women who use prescribed and nonprescribed opioids during pregnancy, including arrest, civil commitment, detention, prosecution, and loss of custody or termination of parental rights. Within the medical community, questions have been raised regarding protocols to detect prenatal drug exposure at delivery, NAS treatment protocols, the need for quality-improvement strategies to standardize care and reduce length of stay for mother and infant, and the benefits of engaging the mother in the care of her infant. It is not uncommon for the expression of strong discordant views on these issues both between and among these political-judicial and medical constituencies. Closely examining the issues often reveal a lack of understanding of substance use disorders, their treatment, and the occurrence and treatment of NAS. This study provides an in-depth examination of NAS, including variations in presentation and factors that impact the efficacy of treatment, and also identifying questions that remain unanswered. Finally, 4 key areas on which future research should focus to guide both medical care and public policy are discussed.

Skin conductance in neonates suffering from abstinence syndrome and unexposed newborns

The aims of this study were to compare the skin conductance (SC) of newborns with opiate-induced neonatal abstinence syndrome (NAS) to that of unexposed newborns and to evaluate the potential of SC readings to detect distress in the context of NAS objectively. The SC of 12 newborns with NAS and 12 unexposed newborns was measured at nine specific times during their first 6 weeks of life. The number of SC fluctuations per second (NSCF/s), the amplitude of SC fluctuation, and the mean level of SC were recorded and analyzed. The SC of newborns treated for symptoms of NAS differed significantly from the SC of unexposed newborns with regard to the NSCF/s (p = 0.04). With the mean level of SC, we observed an interaction between groups over time (p value for interaction = 0.02). With increasing postnatal age, we observed higher values in all three SC parameters.

CONCLUSION

The NSCF/s and the mean level of SC appear to be suitable to reflect the distress of newborns suffering from NAS. As it is known that the sensitivity of SC increases with the level of stress experienced, its potential to indicate elevated stress levels in infants with NAS should be investigated in future studies evaluating different therapy regimens.

WHAT IS KNOWN

• Skin conductance is a result of the filling of palmar and plantar sweat glands innervated by the sympathetic nervous system • Skin conductance can be used as a measure of stress and pain in newborns What is New: • Skin conductance of newborns with neonatal abstinence syndrome (NAS) differs significantly from the SC of non-substance-exposed newborns during the first 6 weeks of life • Skin conductance appears to reflect the increased distress of infants with NAS.

Laser Acupuncture for Neonatal Abstinence Syndrome: A Randomized Controlled Trial

BACKGROUND

Neonatal abstinence syndrome (NAS) is usually treated with opiate derivatives and supported with nonpharmacological treatment.

METHODS

This prospective, randomized, controlled, blinded, single-center study was carried out between March 2009 and November 2014. Newborn infants diagnosed with NAS after maternal opioid substitution therapy were eligible for inclusion. Infants were randomly allocated to the acupuncture group (combining laser acupuncture and pharmacological therapy of morphine and phenobarbital) or control group (pharmacological therapy alone). Laser acupuncture was performed with a LABpen MED 10 (675 nm/10 mW) at 5 ear and 4 body acupuncture points, bilaterally, and sessions were repeated every day. The primary outcome measure was duration of oral morphine therapy for NAS. Secondary outcomes included highest single Finnegan score, time to highest single Finnegan score, maximum amount of oral morphine solution (in milliliters per kilogram and milligrams per kilogram), time to maximum amount of oral morphine solution, and length of hospital stay.

RESULTS

Twenty-eight newborns (14 in each group) were eligible for analysis. Duration of oral morphine therapy was significantly reduced in the acupuncture group compared with the control group (28 vs 39 days, respectively, P = .019). In addition, we observed a significantly reduced length of hospital stay in the acupuncture group compared with the control group (35 days [interquartile range 25 to 47] vs 50 days [36 to 66], P = .048).

CONCLUSIONS

Adjunctive laser acupuncture significantly reduced the duration of morphine therapy in newborns with NAS.

The gestational foundation of sex differences in development and vulnerability

Despite long-standing interest in the role of sex on human development, the functional consequences of fetal sex on early development are not well-understood. Here we explore the gestational origins of sex as a moderator of development. In accordance with the focus of this special issue, we examine evidence for a sex differential in vulnerability to prenatal and perinatal risks. Exposures evaluated include those present in the external environment (e.g., lead, pesticides), those introduced by maternal behaviors (e.g., alcohol, opioid use), and those resulting from an adverse intrauterine environment (e.g., preterm birth). We also provide current knowledge on the degree to which sex differences in fetal neurobehavioral development (i.e., cardiac and motor patterns) are present prior to birth. Also considered are contemporaneous and persistent sex of fetus effects on the pregnant woman. Converging evidence confirms that infant and early childhood developmental outcomes of male fetuses exposed to prenatal and perinatal adversities are more highly impaired than those of female fetuses. In certain circumstances, male fetuses are both more frequently exposed to early adversities and more affected by them when exposed than are female fetuses. The mechanisms through which biological sex imparts vulnerability or protection on the developing nervous system are largely unknown. We consider models that implicate variation in maturation, placental functioning, and the neuroendocrine milieu as potential contributors. Many studies use sex as a control variable, some analyze and report main effects for sex, but those that report interaction terms for sex are scarce. As a result, the true scope of sex differences in vulnerability is unknown.

Genetic determinants of fetal opiate exposure and risk of neonatal abstinence syndrome: Knowledge deficits and prospects for future research

Opiate-dependent pregnant women receive opiate maintenance medications to prevent illicit use and withdrawal. Fetal opiate exposure causes central nervous system (CNS) alterations which manifest as postnatal physical withdrawal. The extensive variability in the Neonatal Abstinence Syndrome phenotype remains unexplained and may be related to variability in fetal exposure and response. Improved understanding of functionally significant genetic variants in pathways influencing placental opiate transfer and fetal response can lead to personalized maternal therapy and optimized neonatal outcomes.

Treating tobacco use disorder in pregnant women in medication-assisted treatment for an opioid use disorder: a systematic review

Smoking is associated with adverse effects on pregnancy and fetal development, yet 88-95% of pregnant women in medication-assisted treatment for an opioid use disorder smoke cigarettes. This review summarizes existing knowledge about smoking cessation treatments for pregnant women on buprenorphine or methadone, the two forms of medication-assisted treatment for opioid use disorder indicated for prenatal use. We performed a systematic review of the literature using indexed terms and key words to capture the concepts of smoking, pregnancy, and opioid substitution and found that only three studies met search criteria. Contingency management, an incentive based treatment, was the most promising intervention: 31% of participants achieved abstinence within the 12-week study period, compared to 0% in a non-contingent behavior incentive group and a group receiving usual care. Two studies of brief behavioral interventions resulted in reductions in smoking but not cessation. Given the growing number of pregnant women in medication-assisted treatment for an opioid use disorder and the negative consequences of smoking on pregnancy, further research is needed to develop and test effective cessation strategies for this group.

Heart rate variability evaluation in the assessment and management of in-utero drug-exposed infants

Aim:

To determine whether heart rate variability parameters vary between in-utero drug-exposed infants and controls. To determine correlations between Finnegan score and heart rate variability parameters. To differentiate those drug-exposed infants who require treatment from those infants who do not.

Methods:

A total of 24 jaundiced control subjects and 25 in-utero drug-exposed infants were enrolled. The Finnegan score and an electrocardiographic rhythm strip were obtained at 4-h intervals. RR intervals (time between consecutive R waves) were manually tabulated from the rhythm strip and analyzed. Time-domain heart rate variability parameters were calculated and analyzed for both groups.

Results:

Heart rate variability parameters were cumulatively lower over 3 days in in-utero drug-exposed infants compared with controls (p < 0.05). Root mean square of differences of standard deviation of RR intervals on first day of life, and standard deviation of RR intervals, percentage of consecutive RR intervals greater than 50 ms, and root mean square of differences of standard deviation of RR intervals on the second day of life were significantly lower between in-utero drug-exposed infants and control infants. Three out of five parameters were significantly lower in in-utero drug-exposed infants pre-treatment versus post-treatment (p = 0.001, p = 0.0001, and p = 0.021, respectively). Root mean square of differences of standard deviation of RR intervals was able to differentiate in-utero drug-exposed infants requiring opiate therapy and in-utero drug-exposed infants that did not (p = 0.02).

Conclusion:

Heart rate variability analysis can contribute to the management of in-utero drug-exposed infants. Heart rate variability could be used in dose titration.

Neonatal abstinence syndrome

Neonatal abstinence syndrome (NAS) is a result of the sudden discontinuation of fetal exposure to substances that were used or abused by the mother during pregnancy. Withdrawal from licit or illicit substances is becoming more common among neonates in both developed and developing countries. NAS continues to be an important clinical entity throughout much of the world. NAS leads to a constellation of signs and symptoms involving multiple systems. The pathophysiology of NAS is not completely understood. Urine or meconium confirmation may assist the diagnosis and management of NAS. The Finnegan scoring system is commonly used to assess the severity of NAS; scoring can be helpful for initiating, monitoring, and terminating treatment in neonates. Nonpharmacological care is the initial treatment option, and pharmacological treatment is required if an improvement is not observed after nonpharmacological measures or if the infant develops severe withdrawal. Morphine is the most commonly used drug in the treatment of NAS secondary to opioids. An algorithmic approach to the management of infants with NAS is suggested. Breastfeeding is not contraindicated in NAS, unless the mother is taking street drugs, is involved in polydrug abuse, or is infected with HIV. Future studies are required to assess the long-term effects of NAS on children after prenatal exposure.

Neonatal abstinence syndrome: evaluating the effectiveness of an evidence-based multidisciplinary care approach

An evidence-based, multidisciplinary neonatal abstinence syndrome protocol was developed using a stepwise continuous quality improvement (CQI) approach with the goal of standardizing care procedures for these infants. A retrospective secondary data analysis was performed to evaluate the differential effects of each step of the CQI project on 4 key clinical outcome measures: length of stay (total and post-opioid wean), weaning time from opioids, and use of adjunct medications. Data were analyzed from 386 newborn infants with a diagnosis of neonatal abstinence syndrome undergoing treatment in a level III neonatal intensive care unit. After implementation of a pharmacologic weaning protocol as a foundational first step of the CQI project, the weaning time from opioids remained stable throughout each of the subsequent CQI steps (P = .905). The overall total neonatal intensive care unit length of stay was reduced by 10.35 days (P = .002), and the length of neonatal intensive care unit stay after completing wean from opioids was reduced by 2.79 days (P < .001). Use of adjunct medications also decreased from 30.1% of infants at the initiation of the CQI project to 24.5% at the completion of the project (P = .020). These findings indicate that this multidisciplinary treatment approach led to an overall improved efficiency of both opioid weaning and symptom management for these infants.

Clinical care for opioid-using pregnant and postpartum women: the role of obstetric providers

We review clinical care issues that are related to illicit and therapeutic opioid use among pregnant women and women in the postpartum period and outline the major responsibilities of obstetrics providers who care for these patients during the antepartum, intrapartum, and postpartum periods. Selected patient treatment issues are highlighted, and case examples are provided. Securing a strong rapport and trust with these patients is crucial for success in delivering high-quality obstetric care and in coordinating services with other specialists as needed. Obstetrics providers have an ethical obligation to screen, assess, and provide brief interventions and referral to specialized treatment for patients with drug use disorders. Opioid-dependent pregnant women often can be treated effectively with methadone or buprenorphine. These medications are classified as pregnancy category C medications by the Food and Drug Administration, and their use in the treatment of opioid-dependent pregnant patients should not be considered "off-label." Except in rare special circumstances, medication-assisted withdrawal during pregnancy should be discouraged because of a high relapse rate. Acute pain management in this population deserves special consideration because patients who use opioids can be hypersensitive to pain and because the use of mixed opioid-agonist/antagonists can precipitate opioid withdrawal. In the absence of other indications, pregnant women who use opioids do not require more intense medical care than other pregnant patients to ensure adequate treatment and the best possible outcomes. Together with specialists in pain and addiction medicine, obstetricians can coordinate comprehensive care for pregnant women who use opioids and women who use opioids in the postpartum period.

[Autonomic regulation and bradycardia during the neonatal period]

The high frequency of bradycardia observed during the neonatal period requires cardiac monitoring but also understanding its intrinsic mechanisms, including responsiveness of the autonomic nervous system (ANS). Heart rate variability and spontaneous baroreflex analysis can help understand the autonomic dysregulation of cardiorespiratory control, possibly responsible for sudden infant death. In clinical neonatology practice, neonatal bradycardia does not warrant continuation of monitoring if it remains isolated, asymptomatic, and short (<10 s), followed by a rapid cardiac acceleration indicating an adapted sympathetic response. Further evaluation of ANS responsiveness is possible for newborns including analyzing the complexity of the heart rate and respiratory variability. This allows better targeting children with high risk after discharge. The real-time evaluation of autonomic regulation could become a valuable tool in clinical practice.

Prenatal substance exposure: neurobiologic organization at 1 month

OBJECTIVE

To examine the autonomic nervous system and neurobehavioral response to a sustained visual attention challenge in 1-month-old infants with prenatal substance exposure.

STUDY DESIGN

We measured heart rate, respiratory sinus arrhythmia, and neurobehavior during sustained visual orientation tasks included in the Neonatal Intensive Care Unit Network Neurobehavioral Scale in 1129 1-month-old infants with prenatal substance exposure. Four groups were compared: infants with prenatal cocaine and opiate exposure, infants with cocaine exposure, infants with opiate exposure, and infants with exposure to other substances (ie, alcohol, marijuana, and tobacco).

RESULTS

The infants with prenatal exposure to both cocaine and opiates had the highest heart rates and lowest levels of respiratory sinus arrhythmia during a sustained visual attention challenge compared with the other 3 groups. Infants with prenatal cocaine and opiate exposure had poorer quality of movement and more hypertonicity during the Neonatal Intensive Care Unit Network Neurobehavioral Scale examination. They also had more nonoptimal reflexes and stress/abstinence signs compared with infants with prenatal exposure to cocaine only and those with prenatal exposure to alcohol, tobacco, and marijuana.

CONCLUSION

Problems with arousal regulation were identified in infants with prenatal substance exposure. Autonomic dysregulation has been implicated as a mechanism by which these difficulties occur. Our results suggest that infants with prenatal exposure to both cocaine and opiates have the greatest autonomic response to the challenge of a sustained visual attention task, possibly putting these infants at risk for problems associated with physiologic and behavioral regulation, a necessary prerequisite for early learning.