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Keane OA, Ourshalimian S, Kaplan C, Gong C, Lakshmanan A, Hintz S, Lee HC, Ing M, Barq R, Nguyen N, Kelley-Quon LI. The Cost of Opioid Use in High-Risk Hospitalized Infants. J Surg Res 2024; 302:825-835. [PMID: 39241291 DOI: 10.1016/j.jss.2024.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 06/18/2024] [Accepted: 07/05/2024] [Indexed: 09/09/2024]
Abstract
INTRODUCTION Hospitalizations of high-risk infants are among the most expensive in the United States, with many requiring surgery and months of intensive care. Healthcare costs and resource use associated with hospitalized infant opioid exposure are less well known. METHODS A retrospective cohort of high-risk infants aged <1 y admitted from 47 children's hospitals from 2010 to 2020 was identified from Pediatric Healthcare Information System. High-risk infants were identified by International Classification of Diseases 9/10 codes for congenital heart disease procedures, medical and surgical necrotizing enterocolitis, extremely low birth weight, very low birth weight, hypoxemic ischemic encephalopathy, extracorporeal membrane oxygenation, and gastrointestinal tract malformations. Healthcare resource utilization was estimated using standardized unit costs (SUCs). The impact of opioid use on SUC was examined using general linear models and an instrumental variable. RESULTS Overall, 126,897 high-risk infants were identified. The cohort was majority White (57.1%), non-Hispanic (72.0%), and male (55.4%). Prematurity occurred in 26.4% and a majority underwent surgery (77.9%). Median SUC was $120,585 (interquartile range: $57,602-$276,562) per infant. On instrumental variable analysis, each day of opioid use was associated with an increase of $4406 in SUC. When adjusting for biologic sex, race, ethnicity, insurance type, diagnosis category, number of comorbidities, mechanical ventilation, and total parental nutrition use, each day of opioid use was associated with an increase of $2177 per infant. CONCLUSIONS Prolonged opioid use is significantly associated with healthcare utilization and costs for high-risk infants, even when accounting for comorbidities, intensive care, ventilation, and total parental nutrition use. Future studies are needed to estimate the long-term complications and additional costs resulting from prolonged opioid exposures in high-risk infants.
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Affiliation(s)
- Olivia A Keane
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California.
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Cameron Kaplan
- USC Gehr Family Center for Health Systems Science and Innovation, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Cynthia Gong
- Division of Neonatology, Department of Pediatrics, Fetal and Neonatal Institute, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Ashwini Lakshmanan
- Department of Health Systems Science, Bernard J. Tyson Kaiser Permanente School of Medicine, Pasadena, California
| | - Susan Hintz
- Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Henry C Lee
- Division of Neonatology, University of California San Diego, La Jolla, California
| | - Madeleine Ing
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Rabab Barq
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Nam Nguyen
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Division of Pediatric Surgery, Memorial Care Miller Children's & Women's Hospital, Long Beach, California
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, California; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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Madurai NK, Jantzie LL, Yen E. Sex differences in neonatal outcomes following prenatal opioid exposure. Front Pediatr 2024; 12:1357970. [PMID: 38577634 PMCID: PMC10991792 DOI: 10.3389/fped.2024.1357970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 03/04/2024] [Indexed: 04/06/2024] Open
Abstract
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.
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Affiliation(s)
- Nethra K. Madurai
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Lauren L. Jantzie
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Neurodevelopmental Medicine, Phelps Center for Cerebral Palsy and Neurodevelopmental Medicine, Kennedy Krieger Institute, Baltimore, MD, United States
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Elizabeth Yen
- Mother Infant Research Institute (MIRI), Tufts Medical Center, Boston, MA, United States
- Division of Newborn Medicine, Tufts Medicine Pediatrics-Boston Children's, Boston, MA, United States
- Department of Pediatrics, Tufts University School of Medicine, Boston, MA, United States
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3
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Keane OA, Ourshalimian S, Lakshmanan A, Lee HC, Hintz SR, Nguyen N, Ing MC, Gong CL, Kaplan C, Kelley-Quon LI. Institutional and Regional Variation in Opioid Prescribing for Hospitalized Infants in the US. JAMA Netw Open 2024; 7:e240555. [PMID: 38470421 PMCID: PMC10936113 DOI: 10.1001/jamanetworkopen.2024.0555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 01/04/2024] [Indexed: 03/13/2024] Open
Abstract
Importance High-risk infants, defined as newborns with substantial neonatal-perinatal morbidities, often undergo multiple procedures and require prolonged intubation, resulting in extended opioid exposure that is associated with poor outcomes. Understanding variation in opioid prescribing can inform quality improvement and best-practice initiatives. Objective To examine regional and institutional variation in opioid prescribing, including short- and long-acting agents, in high-risk hospitalized infants. Design, Setting, and Participants This retrospective cohort study assessed high-risk infants younger than 1 year from January 1, 2016, to December 31, 2022, at 47 children's hospitals participating in the Pediatric Health Information System (PHIS). The cohort was stratified by US Census region (Northeast, South, Midwest, and West). Variation in cumulative days of opioid exposure and methadone treatment was examined among institutions using a hierarchical generalized linear model. High-risk infants were identified by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes for congenital heart disease surgery, medical and surgical necrotizing enterocolitis, extremely low birth weight, very low birth weight, hypoxemic ischemic encephalopathy, extracorporeal membrane oxygenation, and other abdominal surgery. Infants with neonatal opioid withdrawal syndrome, in utero substance exposure, or malignant tumors were excluded. Exposure Any opioid exposure and methadone treatment. Main Outcomes and Measures Regional and institutional variations in opioid exposure. Results Overall, 132 658 high-risk infants were identified (median [IQR] gestational age, 34 [28-38] weeks; 54.5% male). Prematurity occurred in 30.3%, and 55.3% underwent surgery. During hospitalization, 76.5% of high-risk infants were exposed to opioids and 7.9% received methadone. Median (IQR) length of any opioid exposure was 5 (2-12) cumulative days, and median (IQR) length of methadone treatment was 19 (7-46) cumulative days. There was significant hospital-level variation in opioid and methadone exposure and cumulative days of exposure within each US region. The computed intraclass correlation coefficient estimated that 16% of the variability in overall opioid prescribing and 20% of the variability in methadone treatment was attributed to the individual hospital. Conclusions and Relevance In this retrospective cohort study of high-risk hospitalized infants, institution-level variation in overall opioid exposure and methadone treatment persisted across the US. These findings highlight the need for standardization of opioid prescribing in this vulnerable population.
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Affiliation(s)
- Olivia A. Keane
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, California
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, California
| | - Ashwini Lakshmanan
- Department of Health Systems Science, Bernard J. Tyson Kaiser Permanente School of Medicine, Pasadena, California
| | - Henry C. Lee
- Division of Neonatology, University of California San Diego, La Jolla
| | - Susan R. Hintz
- Stanford University School of Medicine, Department of Pediatrics, Division of Neonatology, Palo Alto, California
| | - Nam Nguyen
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, California
- Division of Pediatric Surgery, Memorial Care Miller Children’s & Women’s Hospital, Long Beach, California
| | - Madeleine C. Ing
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, California
| | - Cynthia L. Gong
- Fetal and Neonatal Institute, Division of Neonatology, Department of Pediatrics, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles
| | - Cameron Kaplan
- USC Gehr Family Center for Health Systems Science and Innovation, Keck School of Medicine, University of Southern California, Los Angeles
| | - Lorraine I. Kelley-Quon
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles
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Kelty E, Rae K, Jantzie LL, Wyrwoll CS, Preen DB. Prenatal Opioid Exposure and Immune-Related Conditions in Children. JAMA Netw Open 2024; 7:e2351933. [PMID: 38231512 PMCID: PMC10794935 DOI: 10.1001/jamanetworkopen.2023.51933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 11/28/2023] [Indexed: 01/18/2024] Open
Abstract
Importance Prenatal opioid exposure (POE) may alter with fetal development of the immune system, which may influence long-term health and susceptibility to immune-related conditions. Objective To compare the risk of hospitalization and emergency department presentation for immune-related conditions in children with and without POE. Design, Setting, and Participants This retrospective, population-based cohort study used linked administrative health records of all children born in Western Australia between January 1, 2003, and December 31, 2018 (N = 401 462). Exposure Prenatal exposure to prescription opioids (overall and by trimester), neonatal abstinence syndrome diagnosis, and opioid indication (pain or opioid use disorder [OUD]). Main Outcomes and Measures The main outcome was hospital admissions and emergency department presentations during which a child was diagnosed with an immune-related condition, including infections, conditions associated with an overactive immune system (eg, asthma, eczema, and allergy and anaphylaxis), and autoimmune diseases diagnosed before age 5 years or June 30, 2020. Data were analyzed between August 30, 2022, and February 27, 2023. Results Neonates with POE (1656 [0.4%]; mean [SD] gestational age, 37.7 [2.1] weeks; 836 females [50.5%]; 820 males [49.5%]) were more likely to be born preterm, have low birth weight for gestational age, and be coexposed to cigarette smoke compared with nonexposed neonates. Perinatal opioid exposure was associated with an increased risk of perinatal infection (adjusted odds ratio [AOR], 1.62; 95% CI, 1.38-1.90) and eczema and dermatitis (AOR, 11.91; 95% CI, 9.84-14.41) compared with nonexposure. Neonatal abstinence syndrome was also associated with both conditions (AOR, 2.91 [95% CI, 2.36-3.57] and 31.11 [95% CI, 24.64-39.28], respectively). Prenatal opioid exposure was also associated with an increased risk of childhood asthma (adjusted hazard ratio [AHR], 1.44; 95% CI, 1.16-1.79), but not allergies and anaphylaxis. It was also associated with an increased risk of childhood eczema and dermatitis, but only in children with POE from opioids used to treat OUD (AHR, 1.47; 95% CI, 1.08-1.99) rather than pain. In contrast, POE from opioids used for pain was associated with an increased risk of infection (AHR, 1.44; 95% CI, 1.32-1.58), but POE to opioids used to treat OUD was not. Autoimmune conditions were rare and were not observed to be associated with POE. Conclusions and Relevance In this cohort study, POE was associated with an increased risk of infection, eczema and dermatitis, and asthma, but not allergies and anaphylaxis or autoimmune conditions. These findings highlight the importance of further study of opioid-induced immune changes during pregnancy, the potential impact on long-term health in exposed children, and the mechanisms of opioid-induced immune dysregulation.
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Affiliation(s)
- Erin Kelty
- School of Population and Global Health, The University of Western Australia, Crawley, Western Australia, Australia
| | - Kaitlyn Rae
- School of Human Sciences, The University of Western Australia, Crawley, Western Australia, Australia
| | - Lauren L. Jantzie
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Caitlin S. Wyrwoll
- School of Human Sciences, The University of Western Australia, Crawley, Western Australia, Australia
| | - David B. Preen
- School of Population and Global Health, The University of Western Australia, Crawley, Western Australia, Australia
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Keane OA, Zamora AK, Ourshalimian S, Mahdi EM, Song AY, Kim E, Lakshmanan A, Kim ES, Kelley-Quon LI. Opioid and Methadone Use for Infants With Surgically Treated Necrotizing Enterocolitis. JAMA Netw Open 2023; 6:e2318910. [PMID: 37347485 PMCID: PMC10288332 DOI: 10.1001/jamanetworkopen.2023.18910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 05/02/2023] [Indexed: 06/23/2023] Open
Abstract
Importance Necrotizing enterocolitis (NEC) requiring surgical intervention is the most common reason for surgical procedures in preterm neonates. Opioids are used to manage postoperative pain, with some infants requiring methadone to treat physiologic opioid dependence or wean from nonmethadone opioid treatment during recovery. Objective To describe postoperative opioid use and methadone treatment for infants with surgically treated NEC and evaluate postoperative outcomes. Design, Setting, and Participants A cohort study of infants with surgically treated NEC admitted from January 1, 2013, to December 31, 2022, to 48 Children's Hospital Association hospitals contributing data to the Pediatric Health Information System (PHIS) was performed. Infants who received methadone preoperatively, were aged 14 days or less at the time of the operation, had a congenital heart disease-related operation, or died within 90 days of the operation were excluded. Mixed-effects multivariable logistic regression was used to evaluate thresholds for duration of opioid use after the operation associated with methadone treatment and clinical outcomes associated with methadone use were enumerated. Exposure Postoperative administration of nonmethadone opioids. Main Outcomes and Measures Methadone use and postoperative length of stay, ventilator days, and total parenteral nutrition (TPN) days. Results Of the 2037 infants with surgically treated NEC identified, the median birth weight was 920 (IQR, 700.0-1479.5) g; 1204 were male (59.1%), 911 were White (44.7%), and 343 were Hispanic (16.8%). Infants received nonmethadone opioids for a median of 15 (IQR, 6-30) days after the operation and 231 received methadone (11.3%). The median first day of methadone use was postoperative day 18 (IQR, days 9-64) and continued for 28 days (IQR, 14-73). Compared with infants who received nonmethadone opioids for 1 to 5 days, infants receiving 16 to 21 days of opioids were most likely to receive methadone treatment (odds ratio, 11.45; 95% CI, 6.31-20.77). Methadone use was associated with 21.41 (95% CI, 10.81-32.02) more days of postoperative length of stay, 10.80 (95% CI, 3.63-17.98) more ventilator days, and 16.21 (95% CI, 6.34-26.10) more TPN days. Conclusions and Relevance In this cohort study of infants with surgically treated NEC, prolonged use of nonmethadone opioids after the operation was associated with an increased likelihood of methadone treatment and increased postoperative length of stay, ventilation, and TPN use. Optimizing postoperative pain management for infants requiring an operation may decrease the need for methadone treatment and improve health care use.
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Affiliation(s)
- Olivia A. Keane
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles
| | - Abigail K. Zamora
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, California
| | - Elaa M. Mahdi
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, California
| | - Ashley Y. Song
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Eugene Kim
- Department of Anesthesia, Children’s Hospital Los Angeles, Los Angeles, California
| | - Ashwini Lakshmanan
- Division of Neonatology, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles
| | - Eugene S. Kim
- Department of Surgery, Cedars-Sinai Health System, Los Angeles, California
| | - Lorraine I. Kelley-Quon
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles
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Yen E, Gaddis N, Jantzie L, Davis JM. A review of the genomics of neonatal abstinence syndrome. Front Genet 2023; 14:1140400. [PMID: 36845389 PMCID: PMC9950123 DOI: 10.3389/fgene.2023.1140400] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 02/01/2023] [Indexed: 02/12/2023] Open
Abstract
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.
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Affiliation(s)
- Elizabeth Yen
- Department of Pediatrics, Tufts Medical Center, Boston, MA, United States
- Mother Infant Research Institute, Tufts Medical Center, Boston, MA, United States
- Tufts University School of Medicine, Boston, MA, United States
| | - Nathan Gaddis
- Research Triangle Institute International, Research Triangle Park, Durham, NC, United States
| | - Lauren Jantzie
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jonathan M. Davis
- Department of Pediatrics, Tufts Medical Center, Boston, MA, United States
- Tufts University School of Medicine, Boston, MA, United States
- Tufts Clinical and Translational Sciences Institute, Boston, MA, United States
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Sex-specific inflammatory and white matter effects of prenatal opioid exposure: a pilot study. Pediatr Res 2023; 93:604-611. [PMID: 36280708 PMCID: PMC9998341 DOI: 10.1038/s41390-022-02357-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 09/01/2022] [Accepted: 10/11/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Preclinical data demonstrate that opioids modulate brain reward signaling through an inflammatory cascade, but this relationship has yet to be studied in opioid-exposed neonates. METHODS Saliva samples of 54 opioid-exposed and sex- and age-matched non-exposed neonates underwent transcriptomic analysis of inflammatory and reward genes. A subset of 22 neonates underwent brain magnetic resonance imaging (MRI) to evaluate white matter injury commonly associated with inflammatory response. Gene expression and brain MRI were compared between opioid- and non-exposed neonates and further stratified by sex and pharmacotherapy need. RESULTS Opioid-exposed females regardless of pharmacotherapy need had higher expression of inflammatory genes than their male counterparts, with notable differences in the expression of CCL2 and CXCL1 in females requiring pharmacotherapy (p = 0.01 and 0.06, respectively). Opioid-exposed males requiring pharmacotherapy had higher expression of DRD2 than exposed females (p = 0.07), validating our prior research. Higher expression of IL1β, IL6, TNFα, and IL10 was seen in opioid-exposed neonates with T1 white matter hyperintensity (WMH) compared to exposed neonates without WMH (p < 0.05). CONCLUSION Prenatal opioid exposure may promote inflammation resulting in changes in reward signaling and white matter injury in the developing brain, with unique sex-specific effects. The actions of opioids through non-neuronal pathways need further investigation. IMPACT Opioid-exposed neonates are at risk for punctate T1 white matter hyperintensity (WMH). Females carry a greater propensity for WMH. Salivary transcriptomic data showed significantly higher expression of inflammatory genes in opioid-exposed neonates with WMH than those without WMH, irrespective of pharmacotherapy need. Adding to prior studies, our findings suggest that prenatal opioid exposure may modulate white matter injury and reward signaling through a pro-inflammatory process that is sex specific. This novel study highlights the short-term molecular and structural effects of prenatal opioids and the need to elucidate the long-term impact of prenatal opioid exposure.
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Madurai NK, Kitase Y, Hamimi S, Kirk SE, Sevensky R, Ramachandra S, Muthukumar S, Vasan V, Ozen M, Gerner G, Robinson S, Jantzie LL. Methadone alters the peripheral inflammatory and central immune landscape following prenatal exposure in rats. ADVANCES IN DRUG AND ALCOHOL RESEARCH 2022; 2:10792. [PMID: 37396628 PMCID: PMC10312988 DOI: 10.3389/adar.2022.10792] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Opioid use during pregnancy continues to rise at alarming rates with a parallel trend in the number of infants and children exposed to opioid medications each year. Prenatal opioid exposure (POE) occurs at a critical timepoint in neurodevelopment disrupting intricate pathways essential for neural-immune maturation with the potential for devastating long-term consequences. Understanding the mechanisms underlying injury associated with POE is essential to address long-term outcomes and identify diagnostic and therapeutic biomarkers in this vulnerable patient population. Using an established preclinical model of POE, we investigated changes in cerebral and peripheral inflammation and peripheral blood mononuclear cell (PBMC) activity. We hypothesized that neuroinflammation, as defined by changes in specific cerebral immune cell populations, would exist in adult rats following POE concomitant with sustained peripheral immune hyperreactivity (SPIHR). Our data demonstrated alterations in cerebral immune cells at postnatal day 60 (P60) typified by increased regulatory T cells (p < 0.01) and neutrophils (p < 0.05) in rats with POE compared to controls. Evaluation of serum revealed increased levels of IL-6 (p < 0.05) and CXCL1 (p < 0.05) at P21 in rats with POE compared to controls with no significant difference in cytokine or chemokine levels between the two groups at P60. Additionally, PBMCs isolated from rats with POE at P21 demonstrated baseline hypersecretion of IL-6 (p < 0.01) and SPIHR with increased levels of TNF-α (p < 0.05) and CXCL1 (p < 0.05) following stimulation with LPS. At P60, however, there was no significant difference found in cytokine or chemokine levels secreted by PBMCs isolated from rats with POE at baseline or with LPS stimulation when compared to controls. Taken together, these data demonstrate cerebral inflammation months after prenatal opioid exposure and long after the resolution of systemic inflammation and SPIHR seen at toddler age equivalent. Chronic alterations in the cerebral immune cell populations secondary to prenatal opioid exposure may underly long-term consequences of developmental brain injury including deficits in cognition and attention. These findings may be invaluable to further investigations of precise biomarkers of injury and targeted therapeutics for this vulnerable population.
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Affiliation(s)
- Nethra K. Madurai
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Yuma Kitase
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Sarah Hamimi
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
- Division of Pediatric Neurosurgery, Department of Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Shannon E. Kirk
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Riley Sevensky
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Sindhu Ramachandra
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Sankar Muthukumar
- Division of Pediatric Neurosurgery, Department of Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Vikram Vasan
- Division of Pediatric Neurosurgery, Department of Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Maide Ozen
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Gwendolyn Gerner
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, MD, United States
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Shenandoah Robinson
- Division of Pediatric Neurosurgery, Department of Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Lauren L. Jantzie
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
- Division of Pediatric Neurosurgery, Department of Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
- Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, United States
- Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
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9
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Yen E, Davis JM. The immediate and long-term effects of prenatal opioid exposure. Front Pediatr 2022; 10:1039055. [PMID: 36419918 PMCID: PMC9676971 DOI: 10.3389/fped.2022.1039055] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 10/18/2022] [Indexed: 11/09/2022] Open
Abstract
The opioid epidemic has adversely affected neonates and children, yet the mechanisms by which it impacts this population are not well understood. Not only does prenatal opioid exposure result in short-term consequences shortly after birth, it also creates long-term sequelae that may predispose these children to physical, emotional, psychiatric, cognitive, and socioeconomic problems in the future. This article provides a scoping overview of the long-term effects of antenatal opioid exposure on neonates and children as well as quality improvement and research efforts to understand and mitigate this major public health concern.
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Affiliation(s)
- Elizabeth Yen
- Department of Pediatrics, Tufts Medical Center, Boston, MA, United States
- Mother Infant Research Institute, Tufts Medical Center, Boston, MA, United States
| | - Jonathan M. Davis
- Department of Pediatrics, Tufts Medical Center, Boston, MA, United States
- Tufts Clinical and Translational Science Institute, Boston, MA, United States
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Sex Matters: The Importance of Generating Sex-Based Care Models. Clin Ther 2021; 44:4-5. [PMID: 34974944 DOI: 10.1016/j.clinthera.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 12/10/2021] [Indexed: 11/20/2022]
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11
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Gelernter J, Polimanti R. Genetics of substance use disorders in the era of big data. Nat Rev Genet 2021; 22:712-729. [PMID: 34211176 PMCID: PMC9210391 DOI: 10.1038/s41576-021-00377-1] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2021] [Indexed: 02/06/2023]
Abstract
Substance use disorders (SUDs) are conditions in which the use of legal or illegal substances, such as nicotine, alcohol or opioids, results in clinical and functional impairment. SUDs and, more generally, substance use are genetically complex traits that are enormously costly on an individual and societal basis. The past few years have seen remarkable progress in our understanding of the genetics, and therefore the biology, of substance use and abuse. Various studies - including of well-defined phenotypes in deeply phenotyped samples, as well as broadly defined phenotypes in meta-analysis and biobank samples - have revealed multiple risk loci for these common traits. A key emerging insight from this work establishes a biological and genetic distinction between quantity and/or frequency measures of substance use (which may involve low levels of use without dependence), versus symptoms related to physical dependence.
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Affiliation(s)
- Joel Gelernter
- Department of Psychiatry, Yale University School of Medicine, West Haven, CT, USA.
- Department of Psychiatry, Veterans Affairs Connecticut Healthcare Center, West Haven, CT, USA.
| | - Renato Polimanti
- Department of Psychiatry, Yale University School of Medicine, West Haven, CT, USA
- Department of Psychiatry, Veterans Affairs Connecticut Healthcare Center, West Haven, CT, USA
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12
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Velez ML, Jordan CJ, Jansson LM. Reconceptualizing non-pharmacologic approaches to Neonatal Abstinence Syndrome (NAS) and Neonatal Opioid Withdrawal Syndrome (NOWS): A theoretical and evidence-based approach. Neurotoxicol Teratol 2021; 88:107020. [PMID: 34419619 DOI: 10.1016/j.ntt.2021.107020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 07/12/2021] [Accepted: 08/15/2021] [Indexed: 01/17/2023]
Abstract
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.
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Affiliation(s)
- Martha L Velez
- Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Chloe J Jordan
- Division of Alcohol, Drugs and Addiction, Department of Psychiatry, McLean Hospital/Harvard Medical School, Belmont, MA, USA
| | - Lauren M Jansson
- Johns Hopkins University, School of Medicine, Baltimore, MD, USA.
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13
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Maternal opioid use disorder: Placental transcriptome analysis for neonatal opioid withdrawal syndrome. Genomics 2021; 113:3610-3617. [PMID: 34352367 DOI: 10.1016/j.ygeno.2021.08.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 07/10/2021] [Accepted: 08/01/2021] [Indexed: 01/02/2023]
Abstract
Excessive prenatal opioid exposure may lead to the development of Neonatal Opioid Withdrawal Syndrome (NOWS). RNA-seq was done on 64 formalin-fixed paraffin-embedded placental tissue samples from 32 mothers with opioid use disorder, with newborns with NOWS that required treatment, and 32 prenatally unexposed controls. We identified 93 differentially expressed genes in the placentas of infants with NOWS compared to unexposed controls. There were 4 up- and 89 downregulated genes. Among these, 7 genes CYP1A1, APOB, RPH3A, NRXN1, LINC01206, AL157396.1, UNC80 achieved an FDR p-value of <0.01. The remaining 87 genes were significant with FDR p-value <0.05. The 4 upregulated, CYP1A1, FP671120.3, RAD1, RN7SL856P, and the 10 most significantly downregulated genes were RNA5SP364, GRIN2A, UNC5D, DMBT1P1, MIR3976HG, LINC02199, LINC02822, PANTR1, AC012178.1, CTNNA2. Ingenuity Pathway Analysis identified the 7 most likely to play an important role in the etiology of NOWS. Our study expands insights into the genetic mechanisms of NOWS development.
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14
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Isaac L, van den Hoogen NJ, Habib S, Trang T. Maternal and iatrogenic neonatal opioid withdrawal syndrome: Differences and similarities in recognition, management, and consequences. J Neurosci Res 2021; 100:373-395. [PMID: 33675100 DOI: 10.1002/jnr.24811] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 02/01/2021] [Indexed: 11/12/2022]
Abstract
Opioids are potent analgesics used to manage pain in both young and old, but the increased use in the pregnant population has significant individual and societal implications. Infants dependent on opioids, either through maternal or iatrogenic exposure, undergo neonatal opioid withdrawal syndrome (NOWS), where they may experience withdrawal symptoms ranging from mild to severe. We present a detailed and original review of NOWS caused by maternal opioid exposure (mNOWS) and iatrogenic opioid intake (iNOWS). While these two entities have been assessed entirely separately, recognition and treatment of the clinical manifestations of NOWS overlap. Neonatal risk factors such as age, genetic predisposition, drug type, and clinical factors like type of opioid, cumulative dose of opioid exposure, and disease status affect the incidence of both mNOWS and iNOWS, as well as their severity. Recognition of withdrawal is dependent on clinical assessment of symptoms, and the use of clinical assessment tools designed to determine the need for pharmacotherapy. Treatment of NOWS relies on a combination of non-pharmacological therapies and pharmacological options. Long-term consequences of opioids and NOWS continue to generate controversy, with some evidence of anatomic brain changes, but conflicting animal and human clinical evidence of significant cognitive or behavioral impacts on school-age children. We highlight the current knowledge on clinically relevant recognition, treatment, and consequences of NOWS, and identify new advances in clinical management of the neonate. This review brings a unique clinical perspective and critically analyzes gaps between the clinical problem and our preclinical understanding of NOWS.
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Affiliation(s)
- Lisa Isaac
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, ON, Canada.,Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Nynke J van den Hoogen
- Comparative Biology and Experimental Medicine, Physiology and Pharmacology, Hotchkiss Brain Institute, University of Calgary, Toronto, ON, Canada
| | - Sharifa Habib
- Department of Neonatology, Hospital for Sick Children, Toronto, ON, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Tuan Trang
- Comparative Biology and Experimental Medicine, Physiology and Pharmacology, Hotchkiss Brain Institute, University of Calgary, Toronto, ON, Canada
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15
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Yen E, Maron JL. Aberrant Feeding and Growth in Neonates With Prenatal Opioid Exposure: Evidence of Neuromodulation and Behavioral Changes. Front Pediatr 2021; 9:805763. [PMID: 35127598 PMCID: PMC8814597 DOI: 10.3389/fped.2021.805763] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 12/28/2021] [Indexed: 11/13/2022] Open
Abstract
Opioid use disorder (OUD) among pregnant women over the last decade has led to more than a fivefold increase in the number of neonates born with withdrawal signs known as Neonatal Abstinence Syndrome (NAS) or Neonatal Opioid Withdrawal Syndrome (NOWS). The impact of prenatal opioid exposure on these neonates remains a public health and research priority due to both its short and long-term effects on offspring. Among the adverse long-term effects associated with OUD is a metabolic syndrome with accompanying cardiovascular comorbidities. The susceptibility to metabolic diseases may begin as early as conception. Neonates born in a setting of prenatal opioid exposure are known to have aberrant early growth, e.g., lower birth weight and smaller head size, and dysregulated feeding behavior that ranges from feeding difficulty to hyperphagia which may predispose these neonates to metabolic syndrome in adulthood. However, studies on this topic are lacking. In this article, we describe the reported association between OUD and metabolic syndrome in adults, animal data linking opioid receptors with the development of diet-induced obesity, the inflammatory modulation of opioids and finally, neonatal salivary transcriptomic data from our laboratory that highlighted the sex-specific impact of opioids on the hypothalamic and reward receptors that regulate feeding behavior in opioid-exposed neonates. There is a great need for future research linking opioids with epigenetic and gene expression changes, as well as neuromodulatory effects in the developing brain, that may underlie the dysregulated feeding, growth, and long-term metabolic and cardiovascular risks for these neonates.
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Affiliation(s)
- Elizabeth Yen
- Mother Infant Research Institute, Tufts Medical Center, Boston, MA, United States.,Department of Pediatrics, Tufts University School of Medicine, Boston, MA, United States
| | - Jill L Maron
- Department of Pediatrics, Women & Infants Hospital of Rhode Island, Providence, RI, United States.,Warren Alpert Medical School of Brown University, Providence, RI, United States
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16
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Azuma D, Maron JL. Individualizing Oral Feeding Assessment and Therapies in the Newborn . RESEARCH AND REPORTS IN NEONATOLOGY 2020. [DOI: 10.2147/rrn.s223472] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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17
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Yen E, Kaneko-Tarui T, Maron JL. Technical Considerations and Protocol Optimization for Neonatal Salivary Biomarker Discovery and Analysis. Front Pediatr 2020; 8:618553. [PMID: 33575231 PMCID: PMC7870796 DOI: 10.3389/fped.2020.618553] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 12/31/2020] [Indexed: 12/04/2022] Open
Abstract
Non-invasive techniques to monitor and diagnose neonates, particularly those born prematurely, are a long-sought out goal of Newborn Medicine. In recent years, technical advances, combined with increased assay sensitivity, have permitted the high-throughput analysis of multiple biomarkers simultaneously from a single sample source. Multiplexed transcriptomic and proteomic platforms, along with more comprehensive assays such as RNASeq, allow for interrogation of ongoing physiology and pathology in unprecedented ways. In the fragile neonatal population, saliva is an ideal biofluid to assess clinical status serially and offers many advantages over more invasively obtained blood samples. Importantly, saliva samples are amenable to analysis on emerging proteomic and transcriptomic platforms, even at quantitatively limited volumes. However, biomarker targets are often degraded in human saliva, and as a mixed source biofluid containing both human and microbial targets, saliva presents unique challenges for the investigator. Here, we provide insight into technical considerations and protocol optimizations developed in our laboratory to quantify and discover neonatal salivary biomarkers with improved reproducibility and reliability. We will detail insights learned from years of experimentation on neonatal saliva within our laboratory ranging from salivary collection techniques to processing to downstream analyses, highlighting the need for consistency in approach and a global understanding of both the potential benefits and limitations of neonatal salivary biomarker analyses. Importantly, we will highlight the need for robust and stringent research in this population to provide the field with standardized approaches and workflows to impact neonatal care successfully.
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Affiliation(s)
- Elizabeth Yen
- Mother Infant Research Institute at Tufts Medical Center, Boston, MA, United States.,Division of Newborn Medicine, Tufts Children's Hospital, Boston, MA, United States
| | - Tomoko Kaneko-Tarui
- Mother Infant Research Institute at Tufts Medical Center, Boston, MA, United States
| | - Jill L Maron
- Mother Infant Research Institute at Tufts Medical Center, Boston, MA, United States.,Division of Newborn Medicine, Tufts Children's Hospital, Boston, MA, United States
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18
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Benninger KL, Borghese T, Kovalcik JB, Moore-Clingenpeel M, Isler C, Bonachea EM, Stark AR, Patrick SW, Maitre NL. Prenatal Exposures Are Associated With Worse Neurodevelopmental Outcomes in Infants With Neonatal Opioid Withdrawal Syndrome. Front Pediatr 2020; 8:462. [PMID: 32974241 PMCID: PMC7481438 DOI: 10.3389/fped.2020.00462] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/01/2020] [Indexed: 01/12/2023] Open
Abstract
Aim: To define a developmental trajectory in infants with neonatal opioid withdrawal syndrome (NOWS) and determine whether the impacted developmental domain varies with the type of antenatal exposure. Methods: We performed a retrospective cohort study of infants treated pharmacologically for NOWS and assessed using a standardized schedule for follow-up visits. We compared outcomes of the study population to published norms using one-sample t-tests. Multivariable models examined associations with exposures in addition to opioids. Results: In our cohort of 285 infants with 9-12-months testing, 164 (55.7%) were seen at 3-4 months, and 125 (44%), at 15-18 months. The majority (58%) had intrauterine drug exposures in addition to opioids. Neurodevelopmental scores of infants with NOWS at 3-4 and 9-12 months were not different from published norms. Cognitive and language scores at 15-18 months were worse than published norms. Male sex, older maternal age, and additional barbiturate or alcohol exposure were associated with worse outcomes. Conclusion: Infants with pharmacologically treated NOWS had development similar to unexposed infants during the 1st year but worse cognitive and language scores during the 2nd year. These data support the need for a prospective follow-up of large cohorts of infants with NOWS, with systematic assessments and an evaluation of contributing factors.
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Affiliation(s)
- Kristen L Benninger
- Department of Pediatrics and Neonatology, Nationwide Children's Hospital, Columbus, OH, United States.,Center for Perinatal Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, United States
| | - Teresa Borghese
- Department of Pediatrics and Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Jason B Kovalcik
- Department of Pediatrics and Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Melissa Moore-Clingenpeel
- Biostatistics Core, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, United States
| | - Cherie Isler
- Department of Pediatrics and Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Elizabeth M Bonachea
- Department of Pediatrics and Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Ann R Stark
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Stephen W Patrick
- Departments of Pediatrics and Health Policy, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Nathalie L Maitre
- Department of Pediatrics and Neonatology, Nationwide Children's Hospital, Columbus, OH, United States.,Center for Perinatal Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, United States.,Department of Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, TN, United States
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