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Kristensen AW, Vestermark V, Kjærbye‐Thygesen A, Eckhardt M, Kesmodel US. Maternal opioid use during pregnancy and the risk of neonatal opioid withdrawal syndrome in the offspring. Acta Obstet Gynecol Scand 2024; 103:1522-1529. [PMID: 38700023 PMCID: PMC11266641 DOI: 10.1111/aogs.14850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 04/07/2024] [Accepted: 04/07/2024] [Indexed: 05/05/2024]
Abstract
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.
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Affiliation(s)
- Anna Warncke Kristensen
- Department of Obstetrics and GynecologyNaestved, Slagelse, Ringsted HospitalsSlagelseDenmark
| | - Vibeke Vestermark
- Department of Obstetrics and GynecologyNaestved, Slagelse, Ringsted HospitalsSlagelseDenmark
| | | | | | - Ulrik Schiøler Kesmodel
- Department of Obstetrics and GynecologyAalborg University HospitalAalborgDenmark
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
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Renbarger KM. Factors Influencing Maternal Substance Use and Recovery in the Perinatal Period. West J Nurs Res 2024:1939459241266736. [PMID: 39058287 DOI: 10.1177/01939459241266736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2024]
Abstract
BACKGROUND Substance use disorders (SUD) in the perinatal period have risen dramatically over the past 2 decades. Substance use disorders can have deleterious effects on maternal-infant health. Recovery can improve quality of life but can be challenging for women with SUD in the perinatal period. It is important for health care providers to have an understanding of factors associated with maternal substance use and recovery. OBJECTIVE The purpose of this qualitative review was to identify factors influencing substance use and recovery in women with SUD in the perinatal period. METHODS A systematic search was conducted using the databases of CINAHL, PsycINFO, and PubMed along with a manual search of Google Scholar. The studies were assessed using criteria from the Joanna Briggs Institute's critical appraisal checklist for qualitative research. RESULTS Findings from 16 qualitative studies were synthesized. Six descriptive subthemes identifying factors influencing substance use and recovery were revealed: (1) Infant Care, (2) Stigma, (3) Social Settings Involving Substance Use, (4) Internalized Stigma and Mental Health Symptoms, (5) Addiction Concerns, and (6) Coping Abilities. CONCLUSIONS Participants described external and internal factors that influenced their substance use and recovery. The findings suggest health care providers refer women to residential addiction treatment, use destigmatizing language, promote access to peer services, and provide trauma-informed care.
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Cardin AD. Neonatal Abstinence Syndrome/Neonatal Opioid Withdrawal Syndrome: An Ecological View of Non-Pharmacologic Interventions for Feeding Success. Crit Care Nurs Clin North Am 2024; 36:235-249. [PMID: 38705691 DOI: 10.1016/j.cnc.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
The number of infants diagnosed with neonatal abstinence syndrome (NAS) or neonatal opioid withdrawal syndrome (NOWS) has increased. The expression of NAS/NOWS symptoms differs and typically begins within the first few days of life, considered a critical period for feeding skill establishment, nourishment, and attachment. Non-pharmacologic interventions may be deployed to reduce or eliminate the need for replacement opioids while targeting outcomes like feeding dysfunction. Critical care providers can benefit from a structured examination of disordered feeding experiences to inform their selection of non-pharmacologic interventions. This structure can be provided using the Ecology of Human Performance model.
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Affiliation(s)
- Ashlea D Cardin
- Missouri State University, 901 S. National Avenue, OCHS 203H, Springfield, MO 65897, USA.
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Cooney T, Cote U, Bergen E, Dampier A, Inkila L, Edwards C. Parental Caregivers' Ability to Leave the Postpartum Unit During the COVID-19 Pandemic and Effects on Neonatal Abstinence Syndrome. Nurs Womens Health 2023:S1751-4851(23)00089-2. [PMID: 37269876 PMCID: PMC10232939 DOI: 10.1016/j.nwh.2023.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/21/2023] [Accepted: 04/23/2023] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To determine if a policy change that limited the ability of parental caregivers to leave the postpartum unit during the COVID-19 pandemic influenced neonatal abstinence syndrome (NAS) scores, admissions to the NICU for NAS treatment, and length of stay (LOS) on the nursing unit. DESIGN Retrospective chart review. SETTING /Local Problem: During the pandemic, a change in policy limited parental caregivers from leaving the nursing unit. PARTICIPANTS Neonates being screened for NAS during the period before the policy change from April 2, 2019, through April 1, 2020 (n = 44), and the period after the policy change (n = 23) from April 2, 2020, to April 1, 2021. MEASUREMENTS Levene's test was used to determine homogeneity of variance before independent t tests on mean NAS scores and LOS across groups. A linear mixed-effects model tested differences in NAS scores, accounting for time and group. Chi-square tests determined differences in the number of neonates transferred to the NICU across groups. RESULTS No differences between group variables were found, with the exception of feeding type and cocaine/cannabinoid use (p < .05). No significant differences were found in mean NAS scores (p = .96), LOS (p = .77) or NAS scores accounting for time and between groups (p = .069). Transfers to the NICU in the pre-policy change group were significantly greater (p = .05). CONCLUSION Although no decrease was observed for mean NAS scores and LOS of the neonates, a decrease in transfers to the NICU for pharmacologic treatment for NAS was observed. Further research is required to determine casual relationships for the decrease in NICU transfers.
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Factors Which May Contribute to the Success or Failure of the Use of Mother's Own Milk in a Level IV Neonatal Intensive Care Unit. Adv Neonatal Care 2023; 23:81-92. [PMID: 35670723 DOI: 10.1097/anc.0000000000001003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Benefits of mother's own milk (MOM) for infants in neonatal intensive care units (NICUs) are well known. Many mothers provide for their infant's feedings during their entire hospitalization while others are unable. Knowledge is limited about which infant and maternal factors may contribute most to cessation of MOM feedings. PURPOSE Study aims were to (1) identify which maternal and infant risk factors or combination of factors are associated with cessation of provision of MOM during hospitalization, (2) develop a lactation risk tool to identify neonatal intensive care unit infants at higher risk of not receiving MOM during hospitalization, and (3) identify when infants stop receiving MOM during hospitalization. METHODS A data set of 797 infants admitted into a level IV neonatal intensive care unit before 7 days of age, whose mothers chose to provide MOM, was created from analysis of data from the Children's Hospital Neonatal Database. Maternal and infant factors of 701 dyads who received MOM at discharge were compared with 87 dyads who discontinued use of MOM by discharge using χ 2 , t tests, and Wilcoxon rank tests. Logistic regression was used to build a risk-scoring model. RESULTS The probability of cessation of MOM increased significantly with the number of maternal-infant risk factors. A Risk Calculator was developed to identify dyads at higher risk for cessation of MOM by discharge. IMPLICATIONS FOR PRACTICE Identifying mothers at risk for cessation of MOM can enable the healthcare team to provide optimal lactation management and outcomes. IMPLICATIONS FOR RESEARCH Although the Risk Calculator has potential to identify dyads at risk of early MOM cessation, further research is needed to validate these results.
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Renbarger KM, Phelps B, Broadstreet A, Abebe S. Factors Associated with Maternal Engagement in Infant Care When Mothers Use Substances. WOMEN'S HEALTH REPORTS (NEW ROCHELLE, N.Y.) 2023; 4:48-64. [PMID: 36874237 PMCID: PMC9983138 DOI: 10.1089/whr.2022.0082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 02/09/2023]
Abstract
Introduction Mothers who use substances can play a key role in the treatment and care of their infants. However, challenges exist to engaging these mothers in the care of their infant. The purpose of this study was to identify factors associated with maternal engagement in infant care when mothers are experiencing substance use disorders. Materials and Methods A systematic search was conducted using the databases of CINAHL, APA PsycINFO, and PubMed along with a manual search of Google Scholar between the years of 2012 and 2022. Studies were included if they were (1) original qualitative research; (2) published in English; (3) peer reviewed; (4) from the perspective of mothers who use substances or nurses; (5) included descriptions of interactions between mothers who use substances and their infants during postpartum care, and/or in the nursery or neonatal intensive care unit; and (6) conducted in the United States. The studies were assessed for quality and validity using 10 criteria from the Joanne Briggs Institute critical appraisal checklist for qualitative research. Results Findings from 22 qualitative studies were synthesized using a thematic synthesis approach and revealed 3 overarching themes that included 7 descriptive subthemes that identified factors to maternal engagement. The seven descriptive subthemes included: (1) Attitudes Toward Mothers Who Use Substances; (2) Knowledge on Addiction; (3) Complicated Backgrounds; (4) Emotional Experiences; (5) Managing Infant Symptoms; (6) Model of Postpartum Care; and (7) Hospital Routines. Discussion Participants described stigma from nurses, complex backgrounds of mothers who use substances, and postpartum models that influenced mothers' engagement in infants' care. The findings suggest several clinical implications for nurses. Nurses should manage their biases and approach mothers who use substances in a respectful manner, increase their knowledge of issues and care related to addiction in the perinatal period, and promote family-centered approaches to care. Conclusion The findings of 22 qualitative studies described factors associated with maternal engagement in mothers who use substances that were integrated using a thematic synthesis method. Mothers who use substances have complex backgrounds and experience stigma which can negatively impact their engagement with their infants.
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Affiliation(s)
| | - Barbara Phelps
- School of Nursing, Ball State University, Muncie, Indiana, USA
| | | | - Sheila Abebe
- School of Nursing, Ball State University, Muncie, Indiana, USA
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Developments in Nursing Practice to Address Substance Use in the Perinatal Period. J Obstet Gynecol Neonatal Nurs 2022; 51:361-376. [PMID: 35568096 DOI: 10.1016/j.jogn.2022.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2022] [Indexed: 12/30/2022] Open
Abstract
Since 1972, the year of the inaugural issue of Journal of Obstetric, Gynecologic, & Neonatal Nursing, substance use during pregnancy has remained a public health concern in the United States. This concern is currently exacerbated by factors such as the opioid and stimulant use crisis and widening health and social inequities for many women and families. The purposes of this historical commentary are to describe trends in the perception of women with substance use disorder and their infants and related sociolegal implications and to trace the evolution of related nursing practice and research during the past 50 years. We provide recommendations and priorities for practice and research, including further integration of support for the mother-infant dyad, cross-sectoral collaborations, and equity-oriented practices and policies.
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Renbarger KM, Trainor KE, Place JM, Broadstreet A. Provider Characteristics Associated with Trust When Caring for Women Experiencing Substance Use Disorders in the Perinatal Period. J Midwifery Womens Health 2022; 67:75-94. [DOI: 10.1111/jmwh.13320] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 10/04/2021] [Accepted: 10/06/2021] [Indexed: 01/19/2023]
Affiliation(s)
| | | | - Jean Marie Place
- Department of Science and Nutrition Ball State University Muncie Indiana
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Weber A, Miskle B, Lynch A, Arndt S, Acion L. Substance Use in Pregnancy: Identifying Stigma and Improving Care. Subst Abuse Rehabil 2021; 12:105-121. [PMID: 34849047 PMCID: PMC8627324 DOI: 10.2147/sar.s319180] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 11/02/2021] [Indexed: 11/30/2022] Open
Abstract
This review examines the impact of stigma on pregnant people who use substances. Stigma towards people who use drugs is pervasive and negatively impacts the care of substance-using people by characterizing addiction as a weakness and fostering beliefs that undermine the personal resources needed to access treatment and recover from addiction, including self-efficacy, help seeking and belief that they deserve care. Stigma acts on multiple levels by blaming people for having a problem and then making it difficult for them to get help, but in spite of this, most pregnant people who use substances reduce or stop using when they learn they are pregnant. Language, beliefs about gender roles, and attitudes regarding fitness for parenting are social factors that can express and perpetuate stigma while facilitating punitive rather than therapeutic approaches. Because of stigmatizing attitudes that a person who uses substances is unfit to parent, pregnant people who use substances are at heightened risk of being screened for substance use, referred to child welfare services, and having their parental rights taken away; these outcomes are even more likely for people of color. Various treatment options can successfully support recovery in substance-using pregnant populations, but treatment is underutilized in all populations including pregnant people, and more knowledge is needed on how to sustain engagement in treatment and recovery activities. To combat stigma when working with substance-using pregnant people throughout the peripartum period, caregivers should utilize a trauma-informed approach that incorporates harm reduction and motivational interviewing with a focus on building trust, enhancing self-efficacy, and strengthening the personal skills and resources needed to optimize health of the parent-baby dyad.
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Affiliation(s)
- Andrea Weber
- Department of Psychiatry, University of Iowa Health Care, Iowa City, IA, USA
| | - Benjamin Miskle
- Department of Psychiatry, University of Iowa Health Care, Iowa City, IA, USA
| | - Alison Lynch
- Department of Psychiatry, University of Iowa Health Care, Iowa City, IA, USA
| | - Stephan Arndt
- Department of Biostatistics, University of Iowa, Iowa City, IA, USA
| | - Laura Acion
- Universidad de Buenos Aires - CONICET, Instituto de Cálculo, Ciudad Autónoma de Buenos Aires, Argentina
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Lembeck AL, Tuttle D, Locke R, Lawler L, Jimenez P, Mackley A, Paul DA. Breastfeeding and Formula Selection in Neonatal Abstinence Syndrome. Am J Perinatol 2021; 38:1488-1493. [PMID: 32604445 DOI: 10.1055/s-0040-1713754] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE This study aimed to determine if formula selection, low lactose versus standard term formula, has an effect on outcomes with a comparison to breastfed infants. STUDY DESIGN Retrospective cohort study of neonates ≥35 weeks gestation born with Neonatal Abstinence Syndrome (NAS) was conducted from July 2014 to November 2016. Primary outcomes included length of pharmacologic treatment (LOT), and length of stay (LOS), and weight change per day comparing term standard and low lactose formula majority feeding infants with secondary outcomes comparing breast fed majority feeding infants. RESULTS After investigating feeding methods for 249 NAS infants, a direct comparison of formula groups showed no differences in LOS (3, 95% confidence interval [CI]: -1.1 to 7 days), LOT (3.9, 95% CI: -0.4 to 8.1 days), or weight change per day (-2.4, 95% CI: -11.7 to 6.9 g/day). Breastfeeding improved LOT by 6.9 (95% CI: 3.4-10.5) and 10.8 days (95% CI: 5.9-15.6) and LOS by 7.4 (95% CI: 4.1-10.7) and 10.3 (95% CI: 5.8-14.9) days all reaching significance, in comparison to term and low lactose formula groups, respectively. Weight change per day was greater in the breast versus formula feeding groups when compared individually. CONCLUSION We detected no benefit to low lactose formula in NAS infants. Breastfeeding is associated with clinical reduction in LOS and LOT but is associated with increased weight loss. KEY POINTS · Best formula choice for a neonatal abstinence syndrome (NAS) infant is unknown.. · Many NAS moms cannot breastfeed.. · Low lactose formula has no impact on NAS outcomes..
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Affiliation(s)
- Amy L Lembeck
- Division of Neonatology, Department of Pediatrics, Einstein Medical Center Montgomery, CHOP Newborn Care Network, East Norriton, Pennsylvania
| | - Deborah Tuttle
- Department of Pediatrics, Christiana Care Health System, Newark, Delaware.,Sidney Kimmel School of Medicine at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Robert Locke
- Department of Pediatrics, Christiana Care Health System, Newark, Delaware.,Sidney Kimmel School of Medicine at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Laura Lawler
- Department of Pediatrics, Christiana Care Health System, Newark, Delaware
| | - Pamela Jimenez
- Department of Pediatrics, Christiana Care Health System, Newark, Delaware
| | - Amy Mackley
- Department of Pediatrics, Christiana Care Health System, Newark, Delaware
| | - David A Paul
- Department of Pediatrics, Christiana Care Health System, Newark, Delaware.,Sidney Kimmel School of Medicine at Thomas Jefferson University, Philadelphia, Pennsylvania
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López-Soto D, Griffin PM. Estimating the impact of neonatal abstinence system interventions on Medicaid: an incremental cost analysis. Subst Abuse Treat Prev Policy 2021; 16:91. [PMID: 34930347 PMCID: PMC8691068 DOI: 10.1186/s13011-021-00427-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2021] [Indexed: 11/15/2022] Open
Abstract
Background Neonatal abstinence syndrome (NAS) incidence has significantly increased in the US in recent years. It is therefore important to develop effective intervention protocols that mitigate the long-term consequences of this condition for the mother, her child, and the community. Methods We used Monte Carlo simulation to estimate the impact of four interventions for NAS and their combinations on pregnant women with opioid use disorder. The key outputs were changes in incremental costs from baseline from the Medicaid perspective and from a total systems perspective and effect size changes. Simulation parameters and costs were based on the literature and baseline model validation was performed using Medicaid claims for Indiana. Results Compared to baseline, the resulting simulation estimates showed that three interventions significantly decreased Medicaid incremental costs by 8% (mandatory opioid testing (MOT)), 4% (patient navigators), and 3% (peer recovery coaches). The combination of the three interventions reduced Medicaid direct costs by 26%. Reductions were similar for total system incremental costs (ranging from 2 to 24%), though MOT was found to increase costs of overdose death based on productivity loss. NAS case reductions ranged from 1% (capacity change) to 13% (MOT). Conclusions Using systems-based modeling, we showed that costs associated with NAS can be significantly reduced. However, effective implementation would require the involvement and coordination of several stakeholders. In addition, careful protocols for MOT should be considered to ensure pregnant women don’t forgo prenatal care for fear of punitive consequences. Supplementary Information The online version contains supplementary material available at 10.1186/s13011-021-00427-1.
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Abstract
Supplemental digital content is available in the text. Background Neonatal abstinence syndrome (NAS) rates have dramatically increased. Breastfeeding is a nonpharmacological intervention that may be beneficial, reducing NAS symptom severity and thus the need for and duration of pharmacological treatment and length of hospital stay. Objectives Conduct meta-analysis to determine whether breastfeeding results in better outcomes for NAS infants. Variables included symptom severity, need for and duration of pharmacological treatment, and length of hospital stay. Methods PubMed, Scopus, Embase, and Cochrane Library were searched from 2000 to 2020, and comparative studies examining breastfeeding for NAS infants were extracted. Randomized trials and cohort studies were included. Data were extracted and evaluated with Review Manager Version 5.3. A random-effects model was used to pool discontinuous outcomes using risk ratio and 95% confidence intervals. Continuous outcomes were evaluated by mean differences and 95% confidence intervals. Results Across 11 studies, 6,375 neonates were included in the meta-analysis. Using a random-effects analysis, breastfeeding reduced initiation of pharmacological treatment, reduced duration of pharmacological treatment, and reduced length of stay. No differences were detected for severity of NAS symptoms. Most studies only reported one to two variables of interest. For most studies, these variables were not the primary study outcomes. All studies were found to be of low risk and good quality based on the Cochrane Risk Assessment Tools. Varying breastfeeding definitions limit generalizability. Discussion Breastfeeding is associated with decreased initiation and duration of pharmacological treatment and length of stay.
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Ponder KL, Egesdal C, Kuller J, Joe P. Project Console: a quality improvement initiative for neonatal abstinence syndrome in a children's hospital level IV neonatal intensive care unit. BMJ Open Qual 2021; 10:bmjoq-2020-001079. [PMID: 33941537 PMCID: PMC8098972 DOI: 10.1136/bmjoq-2020-001079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 04/10/2021] [Accepted: 04/19/2021] [Indexed: 12/04/2022] Open
Abstract
Objective To improve care for infants with neonatal abstinence syndrome. Design Infants with a gestational age of ≥35 weeks with prenatal opioid exposure were eligible for our quality improvement initiative. Interventions in our Plan–Do–Study–Act cycles included physician consensus, re-emphasis on non-pharmacological treatment, the Eat Sleep Console method to measure functional impairment, morphine as needed, clonidine and alternative soothing methods for parental unavailability (volunteer cuddlers and automated sleeper beds). Pre-intervention and post-intervention outcomes were compared. Results Length of stay decreased from 31.8 to 10.5 days (p<0.0001) without an increase in readmissions. Composite pharmacotherapy exposure days decreased from 28.7 to 5.5 (p<0.0001). This included reductions in both morphine exposure days (p<0.0001) and clonidine exposure days (p=0.01). Fewer infants required pharmacotherapy (p=0.02). Conclusions Our study demonstrates how a comprehensive initiative can improve care for infants with neonatal abstinence syndrome in an open-bay or a high-acuity neonatal intensive care unit when rooming-in is not available or other comorbidities are present.
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Affiliation(s)
- Kathryn L Ponder
- Neonatology, UCSF Benioff Children's Hospital Oakland, Oakland, California, USA
| | - Charles Egesdal
- Pediatrics, UCSF Benioff Children's Hospital Oakland, Oakland, California, USA
| | - Joanne Kuller
- Neonatology, UCSF Benioff Children's Hospital Oakland, Oakland, California, USA
| | - Priscilla Joe
- Neonatology, UCSF Benioff Children's Hospital Oakland, Oakland, California, USA
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Pahl A, Young L, Buus-Frank ME, Marcellus L, Soll R. Non-pharmacological care for opioid withdrawal in newborns. Cochrane Database Syst Rev 2020; 12:CD013217. [PMID: 33348423 PMCID: PMC8130993 DOI: 10.1002/14651858.cd013217.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The prevalence of substance use, both prescribed and non-prescribed, is increasing in many areas of the world. Substance use by women of childbearing age contributes to increasing rates of neonatal abstinence syndrome (NAS). Neonatal opioid withdrawal syndrome (NOWS) is a newer term describing the subset of NAS related to opioid exposure. Non-pharmacological care is the first-line treatment for substance withdrawal in newborns. Despite the widespread use of non-pharmacological care to mitigate symptoms of NAS, there is not an established definition of, and standard for, non-pharmacological care practices in this population. Evaluation of safety and efficacy of non-pharmacological practices could provide clear guidance for clinical practice. OBJECTIVES To evaluate the safety and efficacy of non-pharmacological treatment of infants at risk for, or having symptoms consistent with, opioid withdrawal on the length of hospitalization and use of pharmacological treatment for symptom management. Comparison 1: in infants at risk for, or having early symptoms consistent with, opioid withdrawal, does non-pharmacological treatment reduce the length of hospitalization and use of pharmacological treatment? Comparison 2: in infants receiving pharmacological treatment for symptoms consistent with opioid withdrawal, does concurrent non-pharmacological treatment reduce duration of pharmacological treatment, maximum and cumulative doses of opioid medication, and length of hospitalization? SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search CENTRAL (2019, Issue 10); Ovid MEDLINE; and CINAHL on 11 October 2019. We also searched clinical trials databases and the reference lists of retrieved articles for randomized controlled trials (RCTs), quasi-RCTs, and cluster trials. SELECTION CRITERIA We included trials comparing single or bundled non-pharmacological interventions to no non-pharmacological treatment or different single or bundled non-pharmacological interventions. We assessed non-pharmacological interventions independently and in combination based on sufficient similarity in population, intervention, and comparison groups studied. We categorized non-pharmacological interventions as: modifying environmental stimulation, feeding practices, and support of the mother-infant dyad. We presented non-randomized studies identified in the search process narratively. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We used the GRADE approach to assess the certainty of evidence. Primary outcomes in infants at risk for, or having early symptoms consistent with, opioid withdrawal included length of hospitalization and pharmacological treatment with one or more doses of opioid or sedative medication. Primary outcomes in infants receiving opioid treatment for symptoms consistent with opioid withdrawal included length of hospitalization, length of pharmacological treatment with opioid or sedative medication, and maximum and cumulative doses of opioid medication. MAIN RESULTS We identified six RCTs (353 infants) in which infants at risk for, or having symptoms consistent with, opioid withdrawal participated between 1975 and 2018. We identified no RCTs in which infants receiving opioid treatment for symptoms consistent with opioid withdrawal participated. The certainty of evidence for all outcomes was very low to low. We also identified and excluded 34 non-randomized studies published between 2005 and 2018, including 29 in which infants at risk for, or having symptoms consistent with, opioid withdrawal participated and five in which infants receiving opioid treatment for symptoms consistent with opioid withdrawal participated. We identified seven preregistered interventional clinical trials that may qualify for inclusion at review update when complete. Of the six RCTs, four studies assessed modifying environmental stimulation in the form of a mechanical rocking bed, prone positioning, non-oscillating waterbed, or a low-stimulation nursery; one study assessed feeding practices (comparing 24 kcal/oz to 20 kcal/oz formula); and one study assessed support of the maternal-infant dyad (tailored breastfeeding support). There was no evidence of a difference in length of hospitalization in the one study that assessed modifying environmental stimulation (mean difference [MD) -1 day, 95% confidence interval [CI) -2.82 to 0.82; 30 infants; very low-certainty evidence) and the one study of support of the maternal-infant dyad (MD -8.9 days, 95% CI -19.84 to 2.04; 14 infants; very low-certainty evidence). No studies of feeding practices evaluated the length of hospitalization. There was no evidence of a difference in use of pharmacological treatment in three studies of modifying environmental stimulation (typical risk ratio [RR) 1.00, 95% CI 0.86 to 1.16; 92 infants; low-certainty evidence), one study of feeding practices (RR 0.92, 95% CI 0.63 to 1.33; 49 infants; very low-certainty evidence), and one study of support of the maternal-infant dyad (RR 0.50, 95% CI 0.13 to 1.90; 14 infants; very low-certainty evidence). Reported secondary outcomes included neonatal intensive care unit (NICU) admission, days to regain birth weight, and weight nadir. One study of support of the maternal-infant dyad reported NICU admission (RR 0.50, 95% CI 0.13 to 1.90; 14 infants; very low-certainty evidence). One study of feeding practices reported days to regain birth weight (MD 1.10 days, 95% CI 2.76 to 0.56; 46 infants; very low-certainty evidence). One study that assessed modifying environmental stimulation reported weight nadir (MD -0.28, 95% CI -1.15 to 0.59; 194 infants; very low-certainty evidence) and one study of feeding practices reported weight nadir (MD -0.8, 95% CI -2.24 to 0.64; 46 infants; very low-certainty evidence). AUTHORS' CONCLUSIONS We are uncertain whether non-pharmacological care for opioid withdrawal in newborns affects important clinical outcomes including length of hospitalization and use of pharmacological treatment based on the six included studies. The outcomes identified for this review were of very low- to low-certainty evidence. Combined analysis was limited by heterogeneity in study design and intervention definitions as well as the number of studies. Many prespecified outcomes were not reported. Although caregivers are encouraged by experts to optimize non-pharmacological care for opioid withdrawal in newborns prior to initiating pharmacological care, we do not have sufficient evidence to inform specific clinical practices. Larger well-designed studies are needed to determine the effect of non-pharmacological care for opioid withdrawal in newborns.
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Affiliation(s)
- Adrienne Pahl
- Pediatrics, University of Vermont Medical Center, Burlington, VT, USA
| | - Leslie Young
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Madge E Buus-Frank
- The Children's Hospital at Dartmouth, Lebanon, New Hampshire, USA
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire, USA
| | | | - Roger Soll
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
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15
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Abstract
BACKGROUND There has been an increase in infants with neonatal abstinence syndrome (NAS) in neonatal intensive care units (NICUs) over the past several decades. Infants with NAS experience withdrawal as a result of the sudden termination at birth of substance exposure during pregnancy. A serious sign related to infants diagnosed with NAS is poor feeding. The prevalence of NAS urges researchers and clinicians to develop effective strategies and techniques to treat and manage the poor feeding of infants exposed to substances in utero. PURPOSE To synthesize current feeding methods and practices used for infants diagnosed with NAS. METHODS/SEARCH STRATEGY PubMed, CINAHL, and Scopus were searched for articles published within the last 20 years that focused on feeding practices or feeding schedules, were written in English, were peer-reviewed, and described human studies. The search terms utilized were "neonatal abstinence syndrome" OR "neonatal opioid withdrawal syndrome" AND "feeding." FINDINGS/RESULTS Three findings emerged regarding techniques and management of poor feeding in the NAS population. The findings included infants who received mother's own milk had decreased severity and later onset of clinical signs of withdrawal, demand feeding is recommended, and the infant's cues may be helpful to follow when feeding. IMPLICATIONS FOR PRACTICE Clinicians should encourage mother's own milk in this population unless contraindications are present. Caregivers and clinicians must be receptive to cues when feeding infants with NAS. IMPLICATIONS FOR RESEARCH Even with the clinical knowledge and experience that infants with NAS are difficult to feed, there is limited research assessing techniques and schedules that are effective in managing successful feeding. Future research should compare feeding schedules such as on-demand feeding versus regimented feeding schedules, as well as investigate techniques that mothers and nurses can utilize to encourage oral intake in this population.Video abstract available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=37.
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16
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Tran EL, Kim SY, England LJ, Green C, Dang EP, Broussard CS, Fehrenbach N, Hudson A, Yowe-Conley T, Gilboa SM, Meaney-Delman D. The MATernaL and Infant NetworK to Understand Outcomes Associated with Treatment of Opioid Use Disorder During Pregnancy (MAT-LINK): Surveillance Opportunity. J Womens Health (Larchmt) 2020; 29:1491-1499. [PMID: 33227221 DOI: 10.1089/jwh.2020.8848] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Pregnant women with opioid use disorder (OUD) are at risk of overdose, infectious diseases, and inadequate prenatal care. Additional risks include adverse pregnancy and infant outcomes, such as preterm birth and neonatal abstinence syndrome. Management and treatment of OUD during pregnancy are associated with improved maternal and infant outcomes. Professional organizations, including the American College of Obstetricians and Gynecologists, recommend offering opioid agonist pharmacotherapy (i.e., methadone or buprenorphine) combined with behavioral therapy as standard treatment for pregnant women with OUD. Other medications and herbal supplements have also been used by pregnant women for OUD. Determining which OUD treatments optimize maternal and infant outcomes is challenging given the host of potential factors that affect these outcomes. The Centers for Disease Control and Prevention initiated the MATernaL and Infant NetworK to Understand Outcomes Associated with Treatment of Opioid Use Disorder during Pregnancy (MAT-LINK) to monitor more than 2000 mothers and their infants, using data collected from geographically diverse clinical sites. Information learned from MAT-LINK will inform the future management and treatment of pregnant women with OUD.
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Affiliation(s)
- Emmy L Tran
- Eagle Global Scientific LLC, San Antonio, Texas, USA.,Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Shin Y Kim
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Lucinda J England
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Caitlin Green
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Elizabeth P Dang
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Cheryl S Broussard
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Nicole Fehrenbach
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Amy Hudson
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Tineka Yowe-Conley
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Suzanne M Gilboa
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Dana Meaney-Delman
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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17
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Dimnjakovic J, Poljicanin T, Svajda M. Breastfeeding: A standard or an intervention? Review of systematic reviews. Med Hypotheses 2020; 141:109737. [DOI: 10.1016/j.mehy.2020.109737] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/06/2020] [Accepted: 04/09/2020] [Indexed: 12/11/2022]
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