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Rana D, Pollard L, Rowland J, Dhanireddy R, Pourcyrous M. Amplitude-integrated EEG in infants with neonatal abstinence syndrome. J Neonatal Perinatal Med 2019; 12:391-397. [PMID: 31356218 DOI: 10.3233/npm-1834] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND To describe amplitude-integrated encephalogram (aEEG) characteristics of neonates with neonatal abstinence syndrome (NAS). METHODS This is a prospective observational study. Newborns exposed to prenatal opioids and their gestational matched controls were included. A single-channel aEEG was obtained using Olympic 6000 CFM monitor. The background activity (continuous/discontinuous), the amplitudes (μV) and the presence of sleep-wake cycle (SWC) were documented. RESULTS A total of 59 infants, 23 with NAS and 36 controls were enrolled. All aEEG were completed within 48 hours of life prior to initiation of treatment. Birth weight and gestational age were similar in both groups. An aEEG was abnormal (discontinuous pattern and/or absent SWC) in 78 % (18/23) of infants with NAS versus only 25% in control group (9/36), [OR 10.8, CI (2.7-46.5) P < 0.001]. 61% of infants with NAS had discontinuous pattern [OR 7.8, CI (2-32) P = 0.001] and 39% had absence of sleep-wake cycle [OR 7.1, CI (1.4-39.4) P = 0.007]. CONCLUSIONS A majority of infants with NAS have abnormal aEEG activity.
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Affiliation(s)
- Divya Rana
- Department of Pediatrics, Division of Neonatology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Leann Pollard
- Department of Pediatrics, Division of Neonatology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jonathan Rowland
- Department of Pediatrics, Division of Neonatology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ramasubbareddy Dhanireddy
- Department of Pediatrics, Division of Neonatology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Massroor Pourcyrous
- Department of Pediatrics, Division of Neonatology, University of Tennessee Health Science Center, Memphis, TN, USA
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Rausgaard NLK, Ibsen IO, Jørgensen JS, Lamont RF, Ravn P. Management and monitoring of opioid use in pregnancy. Acta Obstet Gynecol Scand 2019; 99:7-15. [DOI: 10.1111/aogs.13677] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 05/03/2019] [Accepted: 06/02/2019] [Indexed: 11/28/2022]
Affiliation(s)
| | - Inge Olga Ibsen
- Department of Gynecology and Obstetrics University of Southern Denmark Odense University Hospital Odense Denmark
| | - Jan Stener Jørgensen
- Department of Gynecology and Obstetrics University of Southern Denmark Odense University Hospital Odense Denmark
| | - Ronald Francis Lamont
- Department of Gynecology and Obstetrics University of Southern Denmark Odense University Hospital Odense Denmark
| | - Pernille Ravn
- Department of Gynecology and Obstetrics University of Southern Denmark Odense University Hospital Odense Denmark
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Problematisation and regulation: Bodies, risk, and recovery within the context of Neonatal Abstinence Syndrome. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2018; 68:139-146. [PMID: 30025899 DOI: 10.1016/j.drugpo.2018.06.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 05/01/2018] [Accepted: 06/11/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Neonatal Abstinence Syndrome (NAS) is an anticipated effect of maternal drug use during pregnancy. Yet it remains a contested area of policy and practice. In this paper, we contribute to ongoing debates about the way NAS is understood and responded to, through different treatment regimes, or logics of care. Our analysis examines the role of risk and recovery discourses, and the way in which the bodies of women and babies are conceptualised within these. METHODS Qualitative interviews with 16 parents (9 mothers, 7 fathers) and four focus groups with 27 health and social care professionals based in Scotland. All the mothers were prescribed opioid replacement therapy and parents were interviewed after their baby was born. Data collection explored understandings about the causes and consequences of NAS and experiences of preparing for, and caring for, a baby with NAS. Data were analysed using a narrative and discursive approach. RESULTS Parent and professional accounts simultaneously upheld and subverted logics of care which govern maternal drug use and the assessment and care of mother and baby. Despite acknowledging the unpredictability of NAS symptoms and the inability of the women who are opioid-dependent to prevent NAS, logics of care centred on 'proving' risk and recovery. Strategies appealed to the need for caution, intervening and control, and obscured alternative logics of care that focus on improving support for mother-infant dyads and the family as a whole. CONCLUSION Differing notions of risk and recovery that govern maternal drug use, child welfare and family life both compel and trouble all logics of care. The contentious nature of NAS reflects wider socio-political and moral agendas that ultimately have little to do with meeting the needs of mothers and babies. Fundamental changes in the principles, quality and delivery of care could improve outcomes for families affected by NAS.
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Sutter MB, Gopman S, Leeman L. Patient-centered Care to Address Barriers for Pregnant Women with Opioid Dependence. Obstet Gynecol Clin North Am 2017; 44:95-107. [DOI: 10.1016/j.ogc.2016.11.004] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
Neonatal opioid withdrawal syndrome is common due to the current opioid addiction epidemic. Infants born to women covertly abusing prescription opioids may not be identified as at risk until withdrawal signs present. Buprenorphine is a newer treatment for maternal opioid addiction and appears to result in a milder withdrawal syndrome than methadone. Initial treatment is with nonpharmacological measures including decreasing stimuli, however pharmacological treatment is commonly required. Opioid monotherapy is preferred, with phenobarbital or clonidine uncommonly needed as adjunctive therapy. Rooming-in and breastfeeding may decease the severity of withdrawal. Limited evidence is available regarding long-term effects of perinatal opioid exposure.
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Psychosocial characteristics and poly-drug use of pregnant women enrolled in methadone maintenance treatment. Neurotoxicol Teratol 2013; 38:46-52. [DOI: 10.1016/j.ntt.2013.04.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 04/17/2013] [Accepted: 04/17/2013] [Indexed: 01/06/2023]
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Abstract
UNLABELLED The purpose of this review is to discuss the incidence, risks, pregnancy complications, and maintenance options for treatment of opioid addiction in pregnancy. SUMMARY Opioid dependence in pregnancy carries clear identifiable maternal and fetal risk. Providing care for patients with dependence is best done in a multidisciplinary care model addressing the particular needs of this population. There are limited data on maternal detoxification, with data still emerging surrounding the safety profile of this practice. Historically, methadone has been the recommended maintenance treatment; however, recent data on buprenorphine identify this as a safe and effective option. The majority of births from women with opioid dependence result in neonatal abstinence syndrome requiring prolonged neonatal hospitalization. Intrapartum pain management should not differ from the general obstetric population. Postpartum pain is magnified in this population, and particular attention should be focused on this issue. Breast-feeding is recommended regardless of maintenance dose, unless other conditions restricting breast-feeding are present. Comprehensive postpartum care and transition of care to addiction specialists are highly recommended. TARGET AUDIENCE Obstetricians and gynecologists, family physicians, addiction specialists. LEARNING OBJECTIVES After completing this CME activity, physicians should be better able to assess the treatment options available to patients with opioid addiction during pregnancy, compare the risk/safety profiles of methadone and buprenorphine, and evaluate the recommendations and current data surrounding breast-feeding while on opioid maintenance treatment.
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Kaltenbach K, Holbrook AM, Coyle MG, Heil SH, Salisbury AL, Stine SM, Martin PR, Jones HE. Predicting treatment for neonatal abstinence syndrome in infants born to women maintained on opioid agonist medication. Addiction 2012; 107 Suppl 1:45-52. [PMID: 23106926 PMCID: PMC4268864 DOI: 10.1111/j.1360-0443.2012.04038.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Accepted: 12/10/2011] [Indexed: 11/26/2022]
Abstract
AIM To identify factors that predict the expression of neonatal abstinence syndrome (NAS) in infants exposed to methadone or buprenorphine in utero. DESIGN AND SETTING Multi-site randomized clinical trial in which infants were observed for a minimum of 10 days following birth, and assessed for NAS symptoms by trained raters. PARTICIPANTS A total of 131 infants born to opioid dependent mothers, 129 of whom were available for NAS assessment. MEASUREMENTS Generalized linear modeling was performed using maternal and infant characteristics to predict: peak NAS score prior to treatment, whether an infant required NAS treatment, length of NAS treatment and total dose of morphine required for treatment of NAS symptoms. FINDINGS Of the sample, 53% (68 infants) required treatment for NAS. Lower maternal weight at delivery, later estimated gestational age (EGA), maternal use of selective serotonin re-uptake inhibitors (SSRIs), vaginal delivery and higher infant birthweight predicted higher peak NAS scores. Higher infant birthweight and greater maternal nicotine use at delivery predicted receipt of NAS treatment for infants. Maternal use of SSRIs, higher nicotine use and fewer days of study medication received also predicted total dose of medication required to treat NAS symptoms. No variables predicted length of treatment for NAS. CONCLUSIONS Maternal weight at delivery, estimated gestational age, infant birthweight, delivery type, maternal nicotine use and days of maternal study medication received and the use of psychotropic medications in pregnancy may play a role in the expression of neonatal abstinence syndrome severity in infants exposed to either methadone or buprenorphine.
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Affiliation(s)
- Karol Kaltenbach
- Department of Pediatrics, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA.
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Abstract
PURPOSE The primary aim of this qualitative methods study was to describe the lived experiences of neonatal intensive care unit (NICU) nurses with ethical and morally challenging issues. SUBJECTS The target population for the study was registered nurses working in the NICU. Interviews were completed with 16 nurses from 1 hospital. DESIGN A phenomenological method design was used to describe NICU nurses' lived experiences with ethical and moral issues encountered in the NICU. METHODS After obtaining signed consent, the principal investigator interviewed all participants, using a semistructured interview guide consisting of open-ended questions. MAIN OUTCOMES Ethical and moral distress related to neonatal abstinence syndrome was the predominant outcome. PRINCIPAL RESULTS Caring for infants, coping with families, and discharging infants home were the major concerns voiced by nurses in this study. CONCLUSIONS Nurses in this study struggled with issues of beneficence and nonmaleficence and were not aware of scientific evidence that guides methadone management of pregnant women.
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Höflich AS, Langer M, Jagsch R, Bäwert A, Winklbaur B, Fischer G, Unger A. Peripartum pain management in opioid dependent women. Eur J Pain 2012; 16:574-84. [PMID: 22396085 DOI: 10.1016/j.ejpain.2011.08.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Increased pain sensitivity and the development of opioid tolerance complicate the treatment of pain experiencedby opioid maintained pregnantwomenduring delivery and the perinatal period. Theaim of the present study was to investigate differences in pain management of opioid maintained compared to nondependent pregnant women during delivery and the postpartum period. 40 deliveries of 37 opioid dependent women enrolled in a double-blind, double-dummy randomized controlled trial (RCT) examining the safety and efficacy of methadone (mean dose at the time of delivery = 63.89 mg) and buprenorphine (mean dose at the time of delivery = 14.05 mg) during pregnancy were analyzed and participants were matched to a non-dependent comparison group of 80 pregnant women. Differences in pain management (opioid and non-opioid analgesic medication) during delivery and perinatal period were analyzed. Following cesarean delivery opioid maintained women received significantly less opioid analgesics (day of delivery p = 0.038; day 1: p = 0.02), NSAIDs were administered more frequently to opioid dependent patients than to the comparison group during cesarean section and on the third day postpartum. Significantly higher nicotine consumption in the group of opioid dependentwomenhad a strong influence onthe retrieved results, and might be considered as an independent factor of altered pain experience. Differences in pain treatment became evident when comparing opioid maintained women to healthy controls. These differences might be based on psychosocial consequences of opioid addiction along with the lack of an interdisciplinary consensus on pain treatment protocols for opioid dependent patients.
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Affiliation(s)
- A S Höflich
- Medical University Vienna, Department of Psychiatry and Psychotherapy, Währinger Gürtel 18-20, 1090, Vienna, Austria
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Affiliation(s)
- Sadie Geraghty
- Sadie Geraghty Coordinator of Master of Midwifery Practice and Undergraduate Nursing Lecturer, Edith Cowan University, Perth, Western Australia
| | - Carly Dixon
- Carly Dixon Resident Medical Officer, Fremantle Hospital and Health Service, Western Australia
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Su PH, Chang YZ, Yang C, Ng YY, Chen JY, Chen SC. Perinatal effects of combined use of heroin, methadone, and amphetamine during pregnancy and quantitative measurement of metabolites in hair. Pediatr Neonatol 2012; 53:112-7. [PMID: 22503258 DOI: 10.1016/j.pedneo.2012.01.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Revised: 03/14/2011] [Accepted: 04/15/2011] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE There has been very limited research on the clinical features of newborns exposed to combined use of heroin, methadone, and amphetamine in the uterus. We describe a technique for the quantification of drug metabolites in neonatal hair samples. METHODS In a tertiary neonatal care center in Taiwan, three neonates whose mothers self-reported heroin abuse with methadone treatment during pregnancy were studied. Involuntary exposure to amphetamine was not suspected before the births. To assess long-term illicit drug exposure during pregnancy, a quantifying technique of gas chromatography/mass spectrometry (GC/MS) for hair samples from neonates was developed to replace current methods for urine and blood specimens. RESULTS All three mothers were addicted to heroin and prescribed oral methadone treatment during pregnancy. Two males and one female were born and then admitted to the neonatal intensive care unit because of apparent neonatal abstinence syndrome (NAS) after birth. Additional hypertonicity and cerebral dysfunction were also diagnosed by electroencephalography in one case. Supportive care was given to the neonates, unless special treatments were needed in responding to tachypnea, fetal distress, or withdrawal symptoms. During follow-up periods from 10 months to 15 months, the signs of NAS remained and delays in milestones of development were observed. Further follow-up on the infants' neurobehavioral development is necessary. Measurement results of neonates' hair samples revealed high levels of metabolites of heroin, methadone, and amphetamine, reflecting the amount of illicit drug exposure 2-3 months before delivery. CONCLUSION The current study suggested the possibility of polydrug exposure, which was previously unknown in pregnant women in Taiwan. Measurement of neonatal hair samples could provide a basis for clinical evaluation and potential corresponding treatment.
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Affiliation(s)
- Pen-Hua Su
- Division of Genetics, Department of Pediatrics, Chung Shan Medical University Hospital, Taichung City, Taiwan
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Duration of Methadone Maintenance Treatment During Pregnancy and Pregnancy Outcome Parameters in Women With Opiate Addiction. J Addict Med 2012; 6:18-23. [DOI: 10.1097/adm.0b013e318229bb25] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Leeman LM, Brown SA, Albright B, Skipper B, Hsi A, Rayburn WF. Association between intrapartum fetal heart rate patterns and neonatal abstinence syndrome in methadone exposed neonates. J Matern Fetal Neonatal Med 2010; 24:955-9. [DOI: 10.3109/14767058.2010.536863] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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LIU AJ, JONES MP, MURRAY H, COOK CM, NANAN R. Perinatal risk factors for the neonatal abstinence syndrome in infants born to women on methadone maintenance therapy. Aust N Z J Obstet Gynaecol 2010; 50:253-8. [DOI: 10.1111/j.1479-828x.2010.01168.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Maternal methadone dose during pregnancy and infant clinical outcome. Neurotoxicol Teratol 2010; 32:406-13. [PMID: 20102736 DOI: 10.1016/j.ntt.2010.01.007] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2009] [Revised: 01/12/2010] [Accepted: 01/15/2010] [Indexed: 11/26/2022]
Abstract
In recent decades there has been an increase in the methadone dosages prescribed for opioid dependent women during pregnancy. Using prospective longitudinal data from a cohort of 32 methadone exposed and 42 non-methadone exposed infants, this study examined the relationship between maternal methadone dose during pregnancy and a range of infant clinical outcomes. Of particular interest was the extent to which any observed associations might reflect the direct causal effects of maternal methadone dose and/or the confounding effects of adverse maternal lifestyle factors correlated with methadone use during pregnancy. Findings revealed the presence of clear linear relationships between the mean methadone dose prescribed for mothers during pregnancy and a range of adverse infant clinical outcomes. With increasing maternal methadone dose there was a corresponding increase in infants' risk of being born preterm, being symmetrically smaller, spending longer periods in hospital and the need for treatment for Neonatal Abstinence Syndrome. After due allowance for potentially confounding maternal health and lifestyle factors, maternal methadone dose during pregnancy remained a significant predictor of preterm birth, growth, and the duration of infant hospitalization post delivery. These findings suggest a need to examine more closely the potential impacts of recent trends towards the use of higher methadone dose levels during pregnancy.
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Sarfi M, Martinsen H, Bakstad B, Røislien J, Waal H. Patterns in sleep-wakefulness in three-month old infants exposed to methadone or buprenorphine. Early Hum Dev 2009; 85:773-8. [PMID: 19931991 DOI: 10.1016/j.earlhumdev.2009.10.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2009] [Revised: 09/22/2009] [Accepted: 10/29/2009] [Indexed: 11/17/2022]
Abstract
BACKGROUND Infants exposed to opioides in-utero frequently demonstrate withdrawal symptoms in the neonatal period and have difficulties with state regulation. AIM This study examines sleep-wakefulness-distress patterns as indicators of regulatory mechanisms at 3 months of age. PARTICIPANTS A national infant cohort (N=35) born to women in high-dose maintenance treatment during pregnancy and a comparison group (N=36) of low-risk infants born in the same period. OUTCOME MEASURES Distributions and frequencies of sleep, wakefulness and distress measured in hours and episodes on sleep charts recorded by the mothers in the two groups. RESULTS Women in maintenance treatment were monitored closely during pregnancy to avoid illicit drug use and to be prepared for motherhood. They were also offered residential treatment before pregnancy and after the child was born. There were no statistical differences between the two groups in any of the 10 measures reflecting diurnal and nocturnal rhythmicity at 3 months despite of neonatal abstinence syndrome in 47% of the exposed infants and significant differences in infant characteristics with respect to birth weight, gestational age and maternal characteristics. CONCLUSIONS Follow-up procedures combining drug monitoring and counseling during pregnancy and in the first months after birth enhance the development of state regulation in terms of sleep-wakefulness patterns.
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Affiliation(s)
- Monica Sarfi
- Institute of Psychiatry, Centre for Addiction Research, Oslo University of Oslo, Kirkeveien 166, N-0407 Oslo, Norway.
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