1
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Lowe JR, DiDomenico J, Stephen JM, Roberts MH, Rodriguez DE, Bakhireva LN. Early developmental trajectory of children with prenatal alcohol and opioid exposure. Pediatr Res 2024; 96:471-479. [PMID: 35948606 PMCID: PMC9911560 DOI: 10.1038/s41390-022-02252-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/28/2022] [Accepted: 07/18/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND With significant increases in opioid use/misuse and persistent high prevalence of prenatal alcohol exposure (PAE), identifying infants at risk for long-term developmental sequelae due to these exposures remains an urgent need. This study reports on developmental outcomes in young children from a prospective cohort, ENRICH-1, which recruited pregnant women and followed up maternal-infant pairs. METHODS Subjects were assigned to four study groups based on prenatal use of medications for opioid use disorder (MOUD), PAE, MOUD+PAE, and unexposed controls (UC). Mixed effects modeling was used to evaluate changes in the Bayley Scales of Infant Development-III (BSID-III) Cognitive, Language, and Motor scores between 6 and 20 months. RESULTS There was a significant three-way interaction (MOUD-by-PAE-by-Time) with respect to the BSID-III Cognitive (p = 0.045) and Motor (p = 0.033) scales. Significant changes between the two evaluations were observed for MOUD group in Cognitive and Language scores; for PAE group in Cognitive, Language, and Motor scores, and for MOUD+PAE group in Language scores after adjusting for child sex and family socio-economic status. The developmental scores for the UC remained stable. CONCLUSION Observed decline in neurodevelopmental scores during the first 2 years of life emphasizes the importance of a longitudinal approach when evaluating children with prenatal polysubstance exposure. IMPACT BSID-III scores were stable during the first 2 years of life for unexposed children. BSID-III scores declined for children with prenatal exposures to alcohol and/or opioids. Standard developmental tests may not be sensitive enough during the first year of life. Findings emphasize the need for repeated evaluations of children who are at high risk.
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Affiliation(s)
- Jean R Lowe
- Department of Pediatrics, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Jared DiDomenico
- Substance Use Research and Education (SURE) Center, College of Pharmacy, University of New Mexico, Albuquerque, NM, USA
| | - Julia M Stephen
- The Mind Research Network, a Division of the Lovelace Biomedical Research Institute, Albuquerque, NM, USA
| | - Melissa H Roberts
- Substance Use Research and Education (SURE) Center, College of Pharmacy, University of New Mexico, Albuquerque, NM, USA
| | - Dominique E Rodriguez
- Substance Use Research and Education (SURE) Center, College of Pharmacy, University of New Mexico, Albuquerque, NM, USA
| | - Ludmila N Bakhireva
- Substance Use Research and Education (SURE) Center, College of Pharmacy, University of New Mexico, Albuquerque, NM, USA.
- Department of Family and Community Medicine, School of Medicine, University of New Mexico, Albuquerque, NM, USA.
- Division of Epidemiology, Biostatistics and Preventive Medicine, Department of Internal Medicine, School of Medicine, University of New Mexico, Albuquerque, NM, USA.
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2
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Conradt E, Tronick E, Lester BM. Evidence for neurobehavioral risk phenotypes at birth. Pediatr Res 2024:10.1038/s41390-024-03353-7. [PMID: 38907044 DOI: 10.1038/s41390-024-03353-7] [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: 12/07/2023] [Revised: 03/11/2024] [Accepted: 04/15/2024] [Indexed: 06/23/2024]
Abstract
Observations of newborn behavior provide clinicians and researchers with a first description of the neurobehavioral organization of the newborn that is largely independent of the postnatal environment. The Neonatal Network Neurobehavioral Scale (NNNS) was developed in 2004 to evaluate how prenatal exposure to substances such as cocaine is related to neurobehavioral outcomes. There are now 156 empirical articles published using the NNNS, which we review and summarize. Z-scores from published studies using the NNNS were compiled and aggregated supporting the replicability of three newborn neurobehavioral phenotypes: one typical and two that are predictive of later cognitive and behavioral delay; hyper- and hypo-dysregulated newborns. These phenotypes emerged from independent samples and research groups and were identified in a variety of populations, including infants with prenatal substance exposure, preterm infants, and healthy term infants. Our findings show that newborn neurobehavior can be measured in a reliable and valid manner and that certain behavioral phenotypes, identifiable at birth, can predict neurodevelopmental challenges. These findings have important clinical utility. Intervening early with infants exhibiting these risk phenotypes may prevent later neurodevelopmental delay. IMPACT: We reviewed all empirical studies published using the Neonatal Network Neurobehavioral Scale and found evidence for two replicable stress phenotypes that predict later behavioral outcomes. This study highlights the utility of the Neonatal Network Neurobehavioral Scale for early identification of newborn neurodevelopmental risk phenotypes. Early identification of neurodevelopmental risk, when neuroplasticity is high, may ultimately reduce the burden of subsequent neurobehavioral problems through early intervention.
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Affiliation(s)
- Elisabeth Conradt
- Duke University School of Medicine, Department of Psychiatry and Behavioral Sciences, Durham, NC, USA.
| | - Edward Tronick
- University of Massachusetts Chan Medical School, Departments of Psychiatry and Pediatrics, Worcester, MA, USA
| | - Barry M Lester
- Brown University Alpert Medical School; Departments of Psychiatry and Pediatrics, Providence, RI, USA
- Women and Infants Hospital of Rhode Island, Center for Children and Families, Department of Pediatrics, Providence, RI, USA
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3
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Bektas G, Soderborg T, Slater C, Agarwal J, Racioppi M, Hogan T, Werler MM, Wachman EM. The Neonatal Withdrawal Assessment Tool (NWAT): pilot inter-rater reliability and content validity. J Perinatol 2023; 43:930-935. [PMID: 36914798 DOI: 10.1038/s41372-023-01641-4] [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: 10/29/2022] [Revised: 02/21/2023] [Accepted: 02/24/2023] [Indexed: 03/16/2023]
Abstract
OBJECTIVE There is no validated tool to assess iatrogenic opioid withdrawal in preterm infants in the newborn intensive care unit (NICU). STUDY DESIGN The Neonatal Withdrawal Assessment Tool (NWAT) was developed to address this gap in clinical practice. In this pilot study, the NWAT was assessed for inter-rater reliability (IRR) and content validity. RESULT Fifty-one NICU providers scored two standardized simulated cases, then 20 paired provider assessments were completed on 5 preterm infants. The overall IRR was 95.6% on the simulated cases, and 98.8% on the 5 pilot infants. A provider survey assessed for content validity; all of the provider participants strongly agreed/agreed that the NWAT adequately measures withdrawal in critically ill infants. CONCLUSION The NWAT demonstrated high IRR and content validity for assessment of iatrogenic opioid withdrawal in preterm infants in this pilot study. Further studies in a larger more diverse patient population are needed before wider adoption into clinical practice.
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Affiliation(s)
- Gonca Bektas
- Boston Combined Residency Program in Pediatrics, Boston Medical Center and Boston Children's Hospital, Boston, MA, USA
| | - Taylor Soderborg
- Boston Combined Residency Program in Pediatrics, Boston Medical Center and Boston Children's Hospital, Boston, MA, USA
| | - Cheryl Slater
- Department of Pediatrics, Boston Medical Center, Boston, MA, USA
| | - Joel Agarwal
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | | | - Trystan Hogan
- Department of Pediatrics, Boston Medical Center, Boston, MA, USA
| | - Martha M Werler
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Elisha M Wachman
- Department of Pediatrics, Boston Medical Center, Boston, MA, USA.
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4
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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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5
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Botticello AL, Chen YL, Smith MG, Chung AF, Marchetta CM, McMahon M, Van Orden K, Sulter A, Weinstein L, Zalewitz J, O'Neill J. Transfer Timing and the Length of Medication Weaning for Neonatal Opioid Withdrawal Syndrome. Hosp Pediatr 2023; 13:499-507. [PMID: 37183609 DOI: 10.1542/hpeds.2022-006863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
OBJECTIVE Many infants with neonatal opioid withdrawal syndrome (NOWS) from prenatal exposure to opioids require transfer to a pediatric inpatient unit for medication weaning. The purpose of this study is to assess the difference in the duration of medication weaning between infants transferred by day of life (DOL) 14 versus later (DOL 15 and after) to a tertiary care setting for pharmacological and nonpharmacological management of NOWS. METHODS This single-site retrospective cohort study uses medical chart data from infants with NOWS transferred to specialized care between May 2016 and June 2021 (n = 87). The primary outcome is length of medication weaning, calculated as the number of days between transfer from the NICU to a tertiary care setting and the cessation of pharmacotherapy. RESULTS The majority of the infants in this sample are transferred from acute to tertiary care after DOL 15 (62% versus 38% by DOL 14). The predicted number of days to wean is 14.2 among those infants transferred by DOL 14, whereas the duration of weaning is 6.6 days longer among the later transfer group (20.8 days), adjusting for key covariates. The duration of weaning is also prolonged among infants with greater NOWS symptom severity and with prenatal exposure to psychotropic medications. CONCLUSIONS Delayed treatment prolongs NOWS symptoms and increases the burden on the health care system. Earlier referral from NICUs to pediatric inpatient units with environmental supports could reduce prolonged medication exposure and length of hospitalization for infants diagnosed with NOWS.
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Affiliation(s)
- Amanda L Botticello
- Center for Outcomes and Assessment Research and
- Department of Physical Medicine and Rehabilitation, Rutgers, New Jersey Medical School, Newark, New Jersey
| | - Yu-Lun Chen
- Center for Outcomes and Assessment Research and
- Department of Physical Medicine and Rehabilitation, Rutgers, New Jersey Medical School, Newark, New Jersey
| | | | | | | | - Morgan McMahon
- Children's Specialized Hospital, New Brunswick, New Jersey
| | - Kara Van Orden
- Children's Specialized Hospital, New Brunswick, New Jersey
| | - Amber Sulter
- Children's Specialized Hospital, New Brunswick, New Jersey
| | | | - Jodi Zalewitz
- Children's Specialized Hospital, New Brunswick, New Jersey
| | - John O'Neill
- Center for Employment and Disability Research, Kessler Foundation, West Orange, New Jersey
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6
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Conradt E, Camerota M, Maylott S, Lester BM. Annual Research Review: Prenatal opioid exposure - a two-generation approach to conceptualizing neurodevelopmental outcomes. J Child Psychol Psychiatry 2023; 64:566-578. [PMID: 36751734 DOI: 10.1111/jcpp.13761] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/20/2023] [Indexed: 02/09/2023]
Abstract
Opioid use during pregnancy impacts the health and well-being of two generations: the pregnant person and the child. The factors that increase risk for opioid use in the adult, as well as those that perpetuate risk for the caregiver and child, oftentimes replicate across generations and may be more likely to affect child neurodevelopment than the opioid exposure itself. In this article, we review the prenatal opioid exposure literature with the perspective that this is not a singular event but an intergenerational cascade of events. We highlight several mechanisms of transmission across generations: biological factors, including genetics and epigenetics and the gut-brain axis; parent-child mechanisms, such as prepregnancy experience of child maltreatment, quality of parenting, infant behaviors, neonatal opioid withdrawal diagnosis, and broader environmental contributors including poverty, violence exposure, stigma, and Child Protective Services involvement. We conclude by describing ways in which intergenerational transmission can be disrupted by early intervention.
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Affiliation(s)
- Elisabeth Conradt
- Department of Psychiatry, Duke University, Durham, NC, USA.,Department of Pediatrics, Duke University, Durham, NC, USA
| | - Marie Camerota
- Brown Center for the Study of Children at Risk, Department of Psychiatry and Pediatrics, Alpert Medical School of Brown University and Women and Infants Hospital of Rhode Island, Providence, RI, USA
| | - Sarah Maylott
- Department of Psychiatry, Duke University, Durham, NC, USA
| | - Barry M Lester
- Brown Center for the Study of Children at Risk, Department of Psychiatry and Pediatrics, Alpert Medical School of Brown University and Women and Infants Hospital of Rhode Island, Providence, RI, USA
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7
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Benninger KL, McAllister JM, Merhar SL. Neonatal Opioid Withdrawal Syndrome: An Update on Developmental Outcomes. Clin Perinatol 2023; 50:17-29. [PMID: 36868704 DOI: 10.1016/j.clp.2022.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
Infants and children with prenatal opioid exposure generally have development within the normal range; however, they seem to be at risk for behavioral problems and for lower scores on cognitive, language, and motor assessments than children without prenatal opioid exposure. It is as of yet unclear whether prenatal opioid exposure itself causes issues with development and behavior, or whether it is simply correlated, due to other confounding factors.
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Affiliation(s)
- Kristen L Benninger
- Center for Perinatal Research, The Abigail Wexner Research Institute, Nationwide Children's Hospital, 575 Children's Crossroad, WB 5203, Columbus, OH 43215, USA.
| | - Jennifer M McAllister
- Cincinnati Children's Hospital Perinatal Institute, University of Cincinnati College of Medicine, 3333 Burnet Ave, ML 7009, Cincinnati, OH 45229, USA
| | - Stephanie L Merhar
- Cincinnati Children's Hospital Perinatal Institute, University of Cincinnati College of Medicine, 3333 Burnet Ave, ML 7009, Cincinnati, OH 45229, USA
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8
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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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9
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McGowan EC, Hofheimer JA, O’Shea TM, Kilbride H, Carter BS, Check J, Helderman J, Neal CR, Pastyrnak S, Smith LM, Camerota M, Dansereau LM, Della Grotta SA, Lester BM. Analysis of Neonatal Neurobehavior and Developmental Outcomes Among Preterm Infants. JAMA Netw Open 2022; 5:e2222249. [PMID: 35849396 PMCID: PMC9294999 DOI: 10.1001/jamanetworkopen.2022.22249] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The ability to identify poor outcomes and treatable risk factors among very preterm infants remains challenging; improving early risk detection and intervention targets to potentially address developmental and behavioral delays is needed. OBJECTIVE To determine associations between neonatal neurobehavior using the Neonatal Intensive Care Unit (NICU) Network Neurobehavioral Scale (NNNS), neonatal medical risk, and 2-year outcomes. DESIGN, SETTING, AND PARTICIPANTS This multicenter cohort enrolled infants born at less than 30 weeks' gestation at 9 US university-affiliated NICUs. Enrollment was conducted from April 2014 to June 2016 with 2-year adjusted age follow-up assessment. Data were analyzed from December 2019 to January 2022. EXPOSURES Adverse medical and psychosocial conditions; neurobehavior. MAIN OUTCOMES AND MEASURES Bayley Scales of Infant and Toddler Development, third edition (Bayley-III), cognitive, language, and motor scores of less than 85 and Child Behavior Checklist (CBCL) T scores greater than 63. NNNS examinations were completed the week of NICU discharge, and 6 profiles of neurobehavior were identified by latent profile analysis. Generalized estimating equations tested associations among NNNS profiles, neonatal medical risk, and 2-year outcomes while adjusting for site, maternal socioeconomic and demographic factors, maternal psychopathology, and infant sex. RESULTS A total of 679 enrolled infants had medical and NNNS data; 2-year follow-up data were available for 479 mothers and 556 infants (mean [SD] postmenstrual age at birth, 27.0 [1.9] weeks; 255 [45.9%] female). Overall, 268 mothers (55.9%) were of minority race and ethnicity, and 127 (26.6%) lived in single-parent households. The most common neonatal medical morbidity was BPD (287 [51.7%]). Two NNNS behavior profiles, including 157 infants, were considered high behavioral risk. Infants with at least 2 medical morbidities (n = 123) were considered high medical risk. Infants with high behavioral and high medical risk were 4 times more likely to have Bayley-III motor scores less than 85 compared with those with low behavioral and low medical risk (adjusted relative risk [aRR], 4.1; 95% CI, 2.9-5.1). Infants with high behavioral and high medical risk also had increased risk for cognitive scores less than 85 (aRR, 2.7; 95% CI, 1.8-3.4). Only infants with high behavioral and low medical risk were in the clinical range for CBCL internalizing and total problem scores (internalizing: aRR, 2.3; 95% CI, 1.1-4.5; total: aRR, 2.5; 95% CI, 1.2-4.4). CONCLUSIONS AND RELEVANCE In this study, high-risk neonatal neurobehavioral patterns at NICU discharge were associated with adverse cognitive, motor, and behavioral outcomes at 2 years. Used in conjunction with medical risk, neonatal neurobehavioral assessments could enhance identification of infants at highest risk for delay and offer opportunities to provide early, targeted therapies.
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Affiliation(s)
- Elisabeth C. McGowan
- Department of Pediatrics, Brown Alpert Medical School and Women and Infants Hospital, Providence, Rhode Island
| | - Julie A. Hofheimer
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill
| | - T. Michael O’Shea
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill
| | - Howard Kilbride
- Department of Pediatrics-Neonatology, Children’s Mercy Hospital, Kansas City, Missouri
| | - Brian S. Carter
- Department of Pediatrics-Neonatology, Children’s Mercy Hospital, Kansas City, Missouri
| | - Jennifer Check
- Department of Pediatrics, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Jennifer Helderman
- Department of Pediatrics, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Charles R. Neal
- Department of Pediatrics, University of Hawaii John A. Burns School of Medicine, Honolulu
| | - Steve Pastyrnak
- Department of Pediatrics, Spectrum Health–Helen DeVos Hospital, Grand Rapids, Michigan
| | - Lynne M. Smith
- Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, California
| | - Marie Camerota
- Brown Center for the Study of Children at Risk, Brown Alpert Medical School and Women and Infants Hospital, Providence, Rhode Island
| | - Lynne M. Dansereau
- Brown Center for the Study of Children at Risk, Brown Alpert Medical School and Women and Infants Hospital, Providence, Rhode Island
| | - Sheri A. Della Grotta
- Brown Center for the Study of Children at Risk, Brown Alpert Medical School and Women and Infants Hospital, Providence, Rhode Island
| | - Barry M. Lester
- Department of Psychiatry and Human Behavior, Brown Alpert Medical School, Providence, Rhode Island
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10
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Camerota M, Davis JM, Dansereau LM, Oliveira EL, Padbury JF, Lester BM. Effects of Pharmacologic Treatment for Neonatal Abstinence Syndrome on DNA Methylation and Neurobehavior: A Prospective Cohort Study. J Pediatr 2022; 243:21-26. [PMID: 34971656 PMCID: PMC8960328 DOI: 10.1016/j.jpeds.2021.12.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 11/17/2021] [Accepted: 12/19/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine whether pharmacologic treatment for neonatal abstinence syndrome (NAS) is associated with changes in DNA methylation (DNAm) of the mu-opioid receptor gene (OPRM1) and improvements in neonatal neurobehavior. STUDY DESIGN Buccal swabs were collected from 37 neonates before and after morphine treatment for NAS. Genomic DNA was extracted, and DNAm was examined at 4 cytosine-phosphate-guanine (CpG) sites within the OPRM1 gene. Assessment with the NICU Network Neurobehavioral Scales (NNNS) was also performed before and after NAS treatment. Changes in DNAm (DNAmpost-tx - DNAmpre-tx) and NNNS summary scores (NNNSpost-tx - NNNSpre-tx) were then calculated. Path analysis was used to examine associations among pharmacologic treatment (length of treatment [LOT] and total dose of morphine), changes in DNAm, and changes in NNNS summary scores. RESULTS DNAm was significantly decreased from pretreatment to post-treatment at 1 of 4 CpG sites within the OPRM1 gene. Neonates also demonstrated decreased excitability, hypertonia, lethargy, signs of stress and abstinence, and increased quality of movement and regulation from pretreatment to post-treatment. Longer LOT and higher morphine dose were associated with greater decreases in DNAm; greater decreases in DNAm were associated with greater decreases in excitability and hypertonia on the NNNS. CONCLUSIONS Pharmacologic treatment of NAS is associated with decreased DNAm of the OPRM1 gene and improved neonatal neurobehavior. Epigenetic changes may play a role in these changes in neonatal neurobehavior.
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Affiliation(s)
- Marie Camerota
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI; Department of Pediatrics, Women and Infants Hospital, Providence, RI.
| | - Jonathan M. Davis
- Department of Pediatrics, Tufts Children’s Hospital and the Tufts Clinical and Translational Science Institute, Boston, MA, USA
| | - Lynne M. Dansereau
- Department of Pediatrics, Women and Infants Hospital, Providence, RI, USA
| | - Erica L. Oliveira
- Department of Pediatrics, Women and Infants Hospital, Providence, RI, USA
| | - James F. Padbury
- Department of Pediatrics, Women and Infants Hospital, Providence, RI, USA
| | - Barry M. Lester
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA,Department of Pediatrics, Women and Infants Hospital, Providence, RI, USA
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11
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Lester BM, Davis JM. Disarray in the perinatal management of neonatal abstinence syndrome. Pediatr Res 2022; 91:727-728. [PMID: 34815528 DOI: 10.1038/s41390-021-01848-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 10/31/2021] [Indexed: 11/10/2022]
Affiliation(s)
- Barry M Lester
- Departments of Psychiatry and Pediatrics, Center for the Study of Children at Risk, Alpert Medical School of Brown University, Women and Infants Hospital, Providence, RI, USA.
| | - Jonathan M Davis
- Department of Pediatrics, Tufts Children's Hospital, The Tufts Clinical and Translational Research Institute, Tufts University School of Medicine, Boston, MA, USA
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12
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Rosenfeld CS. The placenta as a target of opioid drugs†. Biol Reprod 2022; 106:676-686. [PMID: 35024817 PMCID: PMC9040663 DOI: 10.1093/biolre/ioac003] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/20/2021] [Accepted: 01/15/2022] [Indexed: 01/14/2023] Open
Abstract
Opioid drugs are analgesics increasingly being prescribed to control pain associated with a wide range of causes. Usage of pregnant women has dramatically increased in the past decades. Neonates born to these women are at risk for neonatal abstinence syndrome (also referred to as neonatal opioid withdrawal syndrome). Negative birth outcomes linked with maternal opioid use disorder include compromised fetal growth, premature birth, reduced birthweight, and congenital defects. Such infants require lengthier hospital stays necessitating rising health care costs, and they are at greater risk for neurobehavioral and other diseases. Thus, it is essential to understand the genesis of such disorders. As the primary communication organ between mother and conceptus, the placenta itself is susceptible to opioid effects but may be key to understanding how these drugs affect long-term offspring health and potential avenue to prevent later diseases. In this review, we will consider the evidence that placental responses are regulated through an endogenous opioid system. However, maternal consumption of opioid drugs can also bind and act through opioid receptors express by trophoblast cells of the placenta. Thus, we will also discuss the current human and rodent studies that have examined the effects of opioids on the placenta. These drugs might affect placental hormones associated with maternal recognition of pregnancy, including placental lactogens and human chorionic gonadotropin in rodents and humans, respectively. A further understanding of how such drugs affect the placenta may open up new avenues for early diagnostic and remediation approaches.
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Affiliation(s)
- Cheryl S Rosenfeld
- Correspondence: Biomedical Sciences, University of Missouri, Columbia, MO 65211, USA. E-mail:
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Abstract
BACKGROUND Neonatal abstinence syndrome (NAS) due to opioid withdrawal may result in disruption of the mother-infant relationship, sleep-wake abnormalities, feeding difficulties, weight loss, seizures and neurodevelopmental problems. OBJECTIVES To assess the effectiveness and safety of using an opioid for treatment of NAS due to withdrawal from opioids in newborn infants. SEARCH METHODS We ran an updated search on 17 September 2020 in CENTRAL via Cochrane Register of Studies Web and MEDLINE via Ovid. We also searched clinical trials databases, conference proceedings and the reference lists of retrieved articles for eligible trials. SELECTION CRITERIA We included randomised controlled trials (RCTs), quasi- and cluster-RCTs which enrolled infants born to mothers with opioid dependence and who were experiencing NAS requiring treatment with an opioid. DATA COLLECTION AND ANALYSIS Three review authors independently assessed trial eligibility and risk of bias, and independently extracted data. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS We included 16 trials (1110 infants) with NAS secondary to maternal opioid use in pregnancy. Seven studies at low risk of bias were included in sensitivity analysis. Opioid versus no treatment / usual care: a single trial (80 infants) of morphine and supportive care versus supportive care alone reported no difference in treatment failure (risk ratio (RR) 1.29, 95% confidence interval (CI) 0.41 to 4.07; very low certainty evidence). No infant had a seizure. The trial did not report mortality, neurodevelopmental disability and adverse events. Morphine increased days hospitalisation (mean difference (MD) 15.00, 95% CI 8.86 to 21.14; very low certainty evidence) and treatment (MD 12.50, 95% CI 7.52 to 17.48; very low certainty evidence), but decreased days to regain birthweight (MD -2.80, 95% CI -5.33 to -0.27) and duration (minutes) of supportive care each day (MD -197.20, 95% CI -274.15 to -120.25). Morphine versus methadone: there was no difference in treatment failure (RR 1.59, 95% CI 0.95 to 2.67; 2 studies, 147 infants; low certainty evidence). Seizures, neonatal or infant mortality and neurodevelopmental disability were not reported. A single study reported no difference in days hospitalisation (MD 1.40, 95% CI -3.08 to 5.88; 116 infants; low certainty evidence), whereas data from two studies found an increase in days treatment (MD 2.71, 95% CI 0.22 to 5.21; 147 infants; low certainty) for infants treated with morphine. A single study reported no difference in breastfeeding, adverse events, or out of home placement. Morphine versus sublingual buprenorphine: there was no difference in treatment failure (RR 0.79, 95% CI 0.36 to 1.74; 3 studies, 113 infants; very low certainty evidence). Neonatal or infant mortality and neurodevelopmental disability were not reported. There was moderate certainty evidence of an increase in days hospitalisation (MD 11.45, 95% CI 5.89 to 17.01; 3 studies, 113 infants), and days treatment (MD 12.79, 95% CI 7.57 to 18.00; 3 studies, 112 infants) for infants treated with morphine. A single adverse event (seizure) was reported in infants exposed to buprenorphine. Morphine versus diluted tincture of opium (DTO): a single study (33 infants) reported no difference in days hospitalisation, days treatment or weight gain (low certainty evidence). Opioid versus clonidine: a single study (31 infants) reported no infant with treatment failure in either group. This study did not report seizures, neonatal or infant mortality and neurodevelopmental disability. There was low certainty evidence for no difference in days hospitalisation or days treatment. This study did not report adverse events. Opioid versus diazepam: there was a reduction in treatment failure from use of an opioid (RR 0.43, 95% CI 0.23 to 0.80; 2 studies, 86 infants; low certainty evidence). Seizures, neonatal or infant mortality and neurodevelopmental disability were not reported. A single study of 34 infants comparing methadone versus diazepam reported no difference in days hospitalisation or days treatment (very low certainty evidence). Adverse events were not reported. Opioid versus phenobarbital: there was a reduction in treatment failure from use of an opioid (RR 0.51, 95% CI 0.35 to 0.74; 6 studies, 458 infants; moderate certainty evidence). Subgroup analysis found a reduction in treatment failure in trials titrating morphine to ≧ 0.5 mg/kg/day (RR 0.21, 95% CI 0.10 to 0.45; 3 studies, 230 infants), whereas a single study using morphine < 0.5 mg/kg/day reported no difference compared to use of phenobarbital (subgroup difference P = 0.05). Neonatal or infant mortality and neurodevelopmental disability were not reported. A single study (111 infants) of paregoric versus phenobarbital reported seven infants with seizures in the phenobarbital group, whereas no seizures were reported in two studies (170 infants) comparing morphine to phenobarbital. There was no difference in days hospitalisation or days treatment. A single study (96 infants) reported no adverse events in either group. Opioid versus chlorpromazine: there was a reduction in treatment failure from use of morphine versus chlorpromazine (RR 0.08, 95% CI 0.01 to 0.62; 1 study, 90 infants; moderate certainty evidence). No seizures were reported in either group. There was low certainty evidence for no difference in days treatment. This trial reported no adverse events in either group. None of the included studies reported time to control of NAS. Data for duration and severity of NAS were limited, and we were unable to use these data in quantitative synthesis. AUTHORS' CONCLUSIONS Compared to supportive care alone, the addition of an opioid may increase duration of hospitalisation and treatment, but may reduce days to regain birthweight and the duration of supportive care each day. Use of an opioid may reduce treatment failure compared to phenobarbital, diazepam or chlorpromazine. Use of an opioid may have little or no effect on duration of hospitalisation or treatment compared to use of phenobarbital, diazepam or chlorpromazine. The type of opioid used may have little or no effect on the treatment failure rate. Use of buprenorphine probably reduces duration of hospitalisation and treatment compared to morphine, but there are no data for time to control NAS with buprenorphine, and insufficient evidence to determine safety. There is insufficient evidence to determine the effectiveness and safety of clonidine.
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Affiliation(s)
- Angelika Zankl
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
- Central Clinical School, School of Medicine, The University of Sydney, Sydney, Australia
| | - Jill Martin
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Jane G Davey
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
| | - David A Osborn
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
- Central Clinical School, School of Medicine, The University of Sydney, Sydney, Australia
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Jenkins DD, Khodaparast N, O'Leary GH, Washburn SN, Covalin A, Badran BW. Transcutaneous Auricular Neurostimulation (tAN): A Novel Adjuvant Treatment in Neonatal Opioid Withdrawal Syndrome. Front Hum Neurosci 2021; 15:648556. [PMID: 33762918 PMCID: PMC7982745 DOI: 10.3389/fnhum.2021.648556] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 02/15/2021] [Indexed: 12/26/2022] Open
Abstract
Maternal opioid use during pregnancy is a growing national problem and can lead to newborns developing neonatal opioid withdrawal syndrome (NOWS) soon after birth. Recent data demonstrates that nearly every 15 min a baby is born in the United States suffering from NOWS. The primary treatment for NOWS is opioid replacement therapy, commonly oral morphine, which has neurotoxic effects on the developing brain. There is an urgent need for non-opioid treatments for NOWS. Transcutaneous auricular neurostimulation (tAN), a novel and non-invasive form of electrostimulation, may serve as a promising alternative to morphine. tAN is delivered via a multichannel earpiece electrode worn on and around the left ear, targeting two cranial nerves—the vagus and trigeminal nerves. Prior research suggests that auricular neurostimulation exerts an anxiolytic effect on the body by releasing endogenous opioids and reduces withdrawal symptoms in adults actively withdrawing from opioids. In this first-in-human prospective, open-label trial, we investigated tAN as an adjuvant to morphine therapy in eight infants >33 weeks gestational age suffering from NOWS and receiving oral morphine treatment. Infants received tAN for 30 min 1 h before receiving a morphine dose. tAN was delivered at 0.1 mA below perception intensity at two different nerve targets on the ear: Region 1, the auricular branch of the vagus nerve; and Region 2, the auriculotemporal nerve. tAN was delivered up to four times daily for a maximum of 12 days. The primary outcome measures were safety [heart rate monitoring, Neonatal Infant Pain Scale (NIPS), and skin irritation] and morphine length of treatment (LOT). tAN was well-tolerated and resulted in no unanticipated adverse events. Comparing to the national average of 23 days, the average oral morphine LOT was 13.3 days (median 9 days) and the average LOT after tAN initiation was 7 days (median 6 days). These preliminary data suggest that tAN is safe and may serve as a promising alternative adjuvant for treating NOWS and reducing the amount of time an infant receives oral morphine.
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Affiliation(s)
- Dorothea D Jenkins
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | | | - Georgia H O'Leary
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States.,Department of Psychiatry & Behavioral Sciences, Brain Stimulation Division, Medical University of South Carolina, Charleston, SC, United States
| | | | | | - Bashar W Badran
- Department of Psychiatry & Behavioral Sciences, Brain Stimulation Division, Medical University of South Carolina, Charleston, SC, United States
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