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Tasket AL, Black MR, Brewer TL, Young ML. Educating Nurses to Improve Awareness and Use of a Human Milk Feeding Care Pathway for Opioid-Exposed Neonates. Nurs Womens Health 2024:S1751-4851(24)00162-4. [PMID: 39153739 DOI: 10.1016/j.nwh.2024.04.004] [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: 02/06/2024] [Revised: 04/03/2024] [Accepted: 07/22/2024] [Indexed: 08/19/2024]
Abstract
OBJECTIVE To increase nurses' awareness and use of a human milk feeding (HMF) and opioid use disorder (OUD) standardized care pathway to improve rates of HMF at discharge in opioid-exposed neonates (OENs). DESIGN Quality improvement project. SETTING/LOCAL PROBLEM Underutilizing an HMF and OUD standardized care pathway in an academic medical center led to declining HMF rates at discharge. PARTICIPANTS Staff nurses in the women and infants department (N = 311). INTERVENTION/MEASUREMENTS Nurses completed an asynchronous online educational module regarding awareness and use of the HMF and OUD standardized care pathway for supporting HMF in OENs. Monthly infographics were placed in each nursing unit to reinforce content. Nurses completed pre- and posteducation surveys to evaluate their knowledge and use of the pathway. After the education, rates of OENs receiving human milk at discharge were collected from the electronic health record. RESULTS A total of 240 (77.2%) nurses participated in the educational module; awareness of the pathway increased from 91.5% to 97.3%. HMF rate at discharge significantly increased from 29.8% to 59.4% (p = .03). CONCLUSION Improved awareness among nurses of a standardized HMF and OUD care pathway was associated with a doubling of HMF rates at discharge in OENs.
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Perez C. Transitioning Care Approach for Neonatal Opioid Withdrawal Syndrome and Neonatal Abstinence Syndrome. Crit Care Nurs Clin North Am 2024; 36:223-233. [PMID: 38705690 DOI: 10.1016/j.cnc.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
The increase in substance use during pregnancy results in a higher incidence of neonatal abstinence syndrome/neonatal opioid withdrawal syndrome (NAS/NOWS), straining health care and social systems and creating an economic burden. There is a paradigm shift in transitioning the care approach for NAS/NOWS from a medical model of care to a family-centered individualized non-pharmacological care approach with non-pharmacological interventions as the first line of treatment. Supporting families after birth with a nurturing environment and providing them with a toolbox of non-pharmacological interventions prepares them for the transition from hospital to home.
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Affiliation(s)
- Christine Perez
- NICU Thought Leader Philips, Infant Massage USA, 8800 Lombard Place 1507, San Diego, CA 92122, USA.
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Robinson TW, Stikes R, Sorrell J, Gater A, Booth AT, Gardner A, Greenwell C, Businger S, Low R, Petrie R. Treatment for Neonatal Abstinence Syndrome using Nonpharmacological Interventions. Am J Perinatol 2024. [PMID: 38729163 DOI: 10.1055/s-0044-1786744] [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] [Indexed: 05/12/2024]
Abstract
OBJECTIVE Management of neonatal abstinence syndrome includes nonpharmacological interventions, but their effectiveness may not be verified before implemented. The objective of this study is to evaluate the effectiveness of a type of bassinet in the treatment of infants with neonatal abstinence syndrome. STUDY DESIGN This is a retrospective observational cohort study. Study setting involved a 24-bed open-bay Level III neonatal intensive care unit located in a metropolitan academic trauma facility. Participant inclusion criteria involved prenatally opioid-exposed infants ≥ 35 weeks with confirmed maternal opioid urine toxicology, required pharmacological treatment for withdrawal symptoms, and were admitted to the neonatal intensive care unit. Three subsets of study participants were analyzed over three different time periods: Group 1 were infants admitted during 2019 without nonpharmacological intervention, Group 2 who were admitted from September 2021 to February 2022 and received nonpharmacological interventions, and Group 3 included those admitted from February 2022 to March 2023 who received the same interventions as Group 2 but were managed in bassinets being used in other local facilities for neonatal abstinence syndrome. RESULTS Group 3 had significant increases in length of stay compared with Group 1 (p = 0.006) and Group 2 (p = 0.013). Group 3 had a significantly greater length of treatment than Group 1 (p = 0.041) and a significantly higher total mg/kg morphine exposure than Group 1 (p = 0.006). CONCLUSION Addition of the bassinet for nonpharmacological management of infants with neonatal abstinence syndrome appeared to prolong length of stay, length of treatment, and increase total mg/kg morphine exposure. As a retrospective nonrandomized study, weakness of low certainty of causality is of concern but findings strongly warrant further research before devices such as the bassinet used in this study are adopted for routine neonatal abstinence syndrome care. KEY POINTS · Special bassinets are promoted to enhance sleep and decrease agitation.. · Such bassinets may assist infants undergoing drug withdrawal.. · Study of the bassinet failed to show benefit to this population..
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Affiliation(s)
- Tonya W Robinson
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky
| | - Reetta Stikes
- Center for Women and Infants, University of Louisville Hospital, Louisville, Kentucky
| | - Jaki Sorrell
- Center for Women and Infants, University of Louisville Hospital, Louisville, Kentucky
| | - Amanda Gater
- Center for Women and Infants, University of Louisville Hospital, Louisville, Kentucky
| | - Adam T Booth
- Center for Women and Infants, University of Louisville Hospital, Louisville, Kentucky
| | - Amanda Gardner
- Center for Women and Infants, University of Louisville Hospital, Louisville, Kentucky
| | - Colleen Greenwell
- Center for Women and Infants, University of Louisville Hospital, Louisville, Kentucky
| | - Shannon Businger
- Center for Women and Infants, University of Louisville Hospital, Louisville, Kentucky
| | - Ryan Low
- Center for Women and Infants, University of Louisville Hospital, Louisville, Kentucky
| | - Rachael Petrie
- Center for Women and Infants, University of Louisville Hospital, Louisville, Kentucky
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Dempsey S, O' Grady MJ. Current management of neonatal abstinence syndrome: a survey of practice in the UK and Ireland. Arch Dis Child Fetal Neonatal Ed 2024; 109:261-264. [PMID: 37879885 DOI: 10.1136/archdischild-2023-326204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 10/11/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVE To study the current management practices of neonatal abstinence syndrome (NAS) throughout the UK and Ireland and identify changes in practice from the most recent survey in 2008. DESIGN Postal questionnaire to a consultant paediatrician or neonatologist in all 215 neonatal units in the UK and Ireland in January 2020. RESULTS Response rate was 62%. An objective scoring tool was used in 97% of units and the Finnegan score was favoured by 70%. Morphine sulfate use as first line for the treatment of opiate withdrawal was almost universal and 70% used a dose of 40 µg/kg every 4 hours (240 µg/kg/day). Phenobarbitone administration as a second-line agent for opiate withdrawal increased to 61% of units with significant reductions in chloral hydrate and chlorpromazine use compared with the previous survey. Morphine sulfate and phenobarbitone remain the preferred first-line and second-line agents, respectively, for polysubstance withdrawal. There was a significant increase in chlorpromazine use as first line for polydrug withdrawal (1.5-14.2%). The practice of units discharging infants' home on medication increased to 46% from 29%. All units now permit breastfeeding in mothers taking methadone, compared with 81% previously. CONCLUSION AND RELEVANCE Compared with the previous survey, improvements in evidence-based practices were noted, highlighting the benefits of this type of research. Nonetheless, significant variation still exists in some aspects of the management of NAS. Post-discharge follow-up varies widely, with particular deficits in ophthalmology follow-up.
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Affiliation(s)
- Sharon Dempsey
- Department of Paediatrics, Regional Hospital Mullingar, Mullingar, Westmeath, Ireland
| | - Michael J O' Grady
- Department of Paediatrics, Regional Hospital Mullingar, Mullingar, Westmeath, Ireland
- Women's and Children's Health, University College Dublin, Dublin, Ireland
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5
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Smith D, Sullivan R, Allen EC, Pradhan S, Zhu J, Oji-Mmuo CN. Evaluating the Effect of Maternal Opioid Maintenance Dose on the NOWS-COS Outcome Criteria: A Pilot Study. Clin Pediatr (Phila) 2024:99228241246647. [PMID: 38629767 DOI: 10.1177/00099228241246647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/23/2024]
Abstract
This retrospective cohort study included 77 mother-infant dyads that delivered term pregnancies at a single tertiary care institution. The primary objective was to investigate whether maternal dose of opioid maintenance therapy during pregnancy affects infant outcomes. All infants had prenatal exposure to opioid maintenance therapies. Maternal dose was converted into morphine milligram equivalents (MMEs) and stratified into high- (MME >1000 mg) and low-dose groups (MME ≤1000 mg). Associations between infant outcomes and MME dosage were examined using Wilcoxon rank-sum and Fisher's Exact tests. Days to symptom control were significantly higher in the high MME group (5 days vs 2.8 days, P = .016). Rates of developmental delay at 24 months were higher in the high MME group (21.2% vs 4.5%, P = .0335). Maternal MME did not predict need for NOWS treatment. Higher MME-exposed infants should have optimized nonpharmacologic interventions for consolation and be increasingly observed for signs of developmental delay.
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Affiliation(s)
- Danielle Smith
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Rhea Sullivan
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Emma C Allen
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Sandeep Pradhan
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Junjia Zhu
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Christiana N Oji-Mmuo
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
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6
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Mascarenhas M, Wachman EM, Chandra I, Xue R, Sarathy L, Schiff DM. Advances in the Care of Infants With Prenatal Opioid Exposure and Neonatal Opioid Withdrawal Syndrome. Pediatrics 2024; 153:e2023062871. [PMID: 38178779 PMCID: PMC10827648 DOI: 10.1542/peds.2023-062871] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 01/06/2024] Open
Abstract
A significant number of advances have been made in the last 5 years with respect to the identification, diagnosis, assessment, and management of infants with prenatal opioid exposure and neonatal opioid withdrawal syndrome (NOWS) from birth to early childhood. The primary objective of this review is to summarize major advances that will inform the clinical management of opioid-exposed newborns and provide an overview of NOWS care to promote the implementation of best practices. First, advances with respect to standardizing the clinical diagnosis of NOWS will be reviewed. Second, the most commonly used assessment strategies are discussed, with a focus on presenting new quality improvement and clinical trial data surrounding the use of the new function-based assessment Eat, Sleep, and Console approach. Third, both nonpharmacologic and pharmacologic treatment modalities are reviewed, highlighting clinical trials that have compared the use of higher calorie and low lactose formula, vibrating crib mattresses, morphine compared with methadone, buprenorphine compared with morphine or methadone, the use of ondansetron as a medication to prevent the need for NOWS opioid pharmacologic treatment, and the introduction of symptom-triggered dosing compared with scheduled dosing. Fourth, maternal, infant, environmental, and genetic factors that have been found to be associated with NOWS severity are highlighted. Finally, emerging recommendations on postdelivery hospitalization follow-up and developmental surveillance are presented, along with highlighting ongoing and needed areas of research to promote infant and family well-being for families impacted by opioid use.
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Affiliation(s)
| | - Elisha M. Wachman
- Department of Pediatrics, Boston Medical Center, and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Iyra Chandra
- Dana Farber Cancer Institute, Boston, Massachusetts
| | - Rachel Xue
- Department of Family Medicine, Boston Medical Center, Boston, Massachusetts
| | - Leela Sarathy
- Newborn Medicine, MassGeneral for Children, Boston, Massachusetts
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7
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Justvig SP, Su J, Clark LM, Messina C, Sridhar S, Mintzer JP. Regional tissue oxygenation in asymptomatic neonates at high risk for neonatal abstinence syndrome and impact of non-pharmacologic interventions: A case report. J Neonatal Perinatal Med 2024; 17:137-145. [PMID: 38160367 DOI: 10.3233/npm-230099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
BACKGROUND Improving neonatal abstinence syndrome (NAS) management is an important concern, and objective measures of its physiologic impact remain elusive. We sought to determine whether near-infrared spectroscopy (NIRS)-derived tissue oxygenation (rSO2) and fractional tissue oxygen extraction (FTOE) demonstrated physiologically plausible changes correlating with standard NAS scoring. METHODS Thirty subjects (mean 39 weeks' GA and 3 127 g BW) underwent cerebral and peripheral muscle NIRS monitoring on Days of Life (DOL) Three, Five, and Seven. We examined correlations between NAS scores and FTOE and assessed the impact of non-pharmacologic swaddling and cuddling. RESULTS No statistically significant correlations between NAS scores and FTOE were observed; however, plausible trends were demonstrated between NAS scores and cerebral measurements. Buprenorphine-exposed babies (57%) showed significantly lower FTOE when swaddled (DOL7). CONCLUSIONS Tissue oxygenation monitoring demonstrates potential to provide objective, clinically relevant physiologic information on infants at risk for NAS. Further study is required to determine whether NIRS-derived measures could assist in individualizing NAS care.
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Affiliation(s)
- S P Justvig
- Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - J Su
- General Surgery, University of Hawaii, Honolulu, HI, USA
| | - L M Clark
- Pediatrics, Stony Brook Children's, Stony Brook, NY, USA
| | - C Messina
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, USA
| | - S Sridhar
- Pediatrics, Stony Brook Children's, Stony Brook, NY, USA
| | - J P Mintzer
- Neonatology, Mountainside Medical Center, Montclair, NJ, USA
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Kushnir A, Bhavsar R, Hanna E, Hegyi T. Neonatal Abstinence Syndrome in Infants with Prenatal Exposure to Methadone versus Buprenorphine. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1030. [PMID: 37371262 DOI: 10.3390/children10061030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 05/31/2023] [Accepted: 06/04/2023] [Indexed: 06/29/2023]
Abstract
Neonatal abstinence syndrome (NAS) has been of increasing concern. Studies suggest that prenatal exposure to buprenorphine may be preferred to methadone in regard to neonatal withdrawal. Our aim was to determine whether the incidence and severity of NAS are different between babies prenatally exposed to methadone or buprenorphine in pregnancy. This retrospective analysis of infants ≥ 35-weeks-old exposed to methadone/buprenorphine alone or in conjunction with other substances in utero. They were divided into four groups: 1-methadone alone (Met), 2-buprenorphine alone (Bup), 3 and 4-those exposed to methadone and buprenorphine, respectively, in conjunction with other drugs (Met+ and Bup+). The frequency of NAS treatment, duration of treatment (LOT) and length of stay (LOS) were compared between groups. Of the 290 mothers, 59% were in the Met group, 18% in the Bup group, 14% in the Met or Bup and another opiate group, and 9% took methadone or buprenorphine plus various other substances. Infants born to Met/Met+ mothers had a four-times higher likelihood of developing NAS (p < 0.001). There was no difference in the LOS (p = 0.08) or LOT (p = 0.11) between groups. The buprenorphine treatment in pregnancy decreased the risk of babies developing NAS. However, once the NAS required pharmacological treatment, the type of maternal prenatal exposure did not affect the LOS or LOT.
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Affiliation(s)
- Alla Kushnir
- Division of Neonatology, Department of Pediatric, Cooper University Hospital, Camden, NJ 08103, USA
| | - Ravi Bhavsar
- Division of Neonatology, Department of Pediatric, Cooper University Hospital, Camden, NJ 08103, USA
| | - Emad Hanna
- Division of Neonatology, Department of Pediatrics, Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA
| | - Thomas Hegyi
- Division of Neonatology, Department of Pediatrics, Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA
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Bremer MJ, Knippen KL. Breastfeeding Experiences in Women from Ten States Reporting Opioid Use Before or During Pregnancy: PRAMS, Phase 8. Matern Child Health J 2023; 27:747-756. [PMID: 35947276 DOI: 10.1007/s10995-022-03497-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 07/11/2022] [Accepted: 07/18/2022] [Indexed: 10/15/2022]
Abstract
INTRODUCTION Evidence of opioid use at hospital delivery has increased over the past two decades, increasing risk of neonatal withdrawal. Breastfeeding may improve infant outcomes, but little is known about breastfeeding experiences of women who have a history of opioid use prior to or during pregnancy. This study aimed to determine if self-reported opioid use prior to or during pregnancy impacted breastfeeding, specifically attempt to breastfeed, duration of breastfeeding, assessment of prenatal breastfeeding intention, source of breastfeeding information, and early hospital experiences. METHODS Data from ten states (n = 10,550) that evaluated opioid use in the 2016 Pregnancy Risk Assessment Monitoring System survey were included. Weighted univariate and multivariate linear and logistic regression were calculated. The multivariate regression also included adjustment for covariates. RESULTS Among the overall sample, 939 participants reported opioid exposure before or during pregnancy. We found no significant difference in breastfeeding attempt. Breastfeeding for at least 6, 10, or 20 weeks was significantly less likely in participants reporting opioid exposure. Exposure correlated with lower odds of skin-to-skin contact, infant being fed in the first hour, exclusive breastfeeding in the hospital, and feeding on demand. Hospital pacifier use was associated with opioid exposure. CONCLUSION While we found no difference in breastfeeding attempt, we did observe significant differences in breastfeeding duration and early hospital experiences which may represent modifiable gaps in clinical practice. Future work should focus on optimizing early hospital experiences and support when breastfeeding is clinically indicated.
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Affiliation(s)
- Madeleine Jade Bremer
- Food Service Director and Community Nutrition Educator, Camp Beechpoint 3212 125th Ave, Allegan, Michigan, USA
| | - Kerri Lynn Knippen
- Department of Public & Allied Health, Bowling Green State University, 122 Health & Human Services Building, Bowling Green, OH, USA.
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Management of Newborns With In Utero Substance Exposure: AWHONN Practice Brief Number 18. Nurs Womens Health 2023; 27:e8-e11. [PMID: 36907796 DOI: 10.1016/j.nwh.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
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Management of Newborns With In Utero Substance Exposure: AWHONN Practice Brief Number 18. J Obstet Gynecol Neonatal Nurs 2023; 52:e1-e4. [PMID: 36907797 DOI: 10.1016/j.jogn.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
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A Scoping Review of Neonatal Opioid Withdrawal and the Infant Gut Microbiome: Does Human Milk Optimize Infant Outcomes? Adv Neonatal Care 2023; 23:237-245. [PMID: 36867674 DOI: 10.1097/anc.0000000000001056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
BACKGROUND While a growing body of literature has established the role of human milk as a mechanism of protection in the formation of the infant gut microbiome, it remains unclear the extent to which this association exists for infants with neonatal opioid withdrawal syndrome. PURPOSE The purpose of this scoping review was to describe the current state of the literature regarding the influence of human milk on infant gut microbiota in infants with neonatal opioid withdrawal syndrome. DATA SOURCES CINAHL, PubMed, and Scopus databases were searched for original studies published from January 2009 through February 2022. Additionally, unpublished studies across relevant trial registries, conference proceedings, websites, and organizations were reviewed for possible inclusion. A total of 1610 articles met selection criteria through database and register searches and 20 through manual reference searches. STUDY SELECTION Inclusion criteria were primary research studies, written in English, published between 2009 and 2022, including a sample of infants with neonatal opioid withdrawal syndrome/neonatal abstinence syndrome, and focusing on the relationship between the receipt of human milk and the infant gut microbiome. DATA EXTRACTION Two authors independently conducted title/abstract and full-text review until there was consensus of study selection. RESULTS No studies satisfied the inclusion criteria, which resulted in an empty review. IMPLICATIONS FOR PRACTICE AND RESEARCH Findings from this study document the paucity of data exploring the associations between human milk, the infant gut microbiome, and subsequent neonatal opioid withdrawal syndrome. Further, these results highlight the timely importance of prioritizing this area of scientific inquiry.
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de Castro KN, Benson JD, Thomas H, Manuel V, Mitra S. Feasibility of Implementing a Modified SENSE Program to Increase Positive Sensory Experiences for Preterm Infants in the Neonatal Intensive Care Unit (NICU): A Pilot Study. Phys Occup Ther Pediatr 2023; 43:109-128. [PMID: 35903855 DOI: 10.1080/01942638.2022.2104150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIMS To evaluate the feasibility of implementing the Supporting and Enhancing NICU Sensory Experiences (SENSE) program with adaptations to increase positive sensory exposure for infants born preterm, support neonatal neurodevelopment, and decrease parent stress. METHODS Eight infants born between 28 and 33 weeks were recruited within one week of birth. Parents, trained in the program, delivered the SENSE protocol. The first author provided up to 1 h of sensory input on weekdays when a parent could not be present. RESULTS Recruitment and retention rates were 87.5% and 100%, respectively. Recruitment and initial parent education and training averaged 37.5 min. On average, parents were present in the NICU 85.1% of days; they participated in SENSE for an average of 515.5 min. SENSE dose recommendations were not consistently met. Weekly infant assessments and regular parent check ins averaged 22.5 and 13.8 min, respectively. Post-assessments revealed normal scores on a neurodevelopmental assessment, low parent stress, and high parent satisfaction. CONCLUSIONS The recruitment and retention rates suggest high demand to participate. Outcomes for parent stress and neonatal neurodevelopment support continuation of SENSE. Time commitment for implementation, coupled with supporting families in meeting dose recommendations, suggest a need for a neonatal therapist to promote sustainability.
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Affiliation(s)
| | - Jeryl D Benson
- Department of Occupational Therapy, Rangos School of Health Sciences, Duquesne University, Pittsburgh, Pennsylvania, USA
| | - Hillary Thomas
- West Penn Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Vinit Manuel
- West Penn Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Sanjay Mitra
- West Penn Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
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Morrison TM, MacMillan KDL, Melvin P, Singh R, Murzycki J, Van Vleet MW, Rothstein R, O'Shea TF, Gupta M, Schiff DM, Wachman EM. Neonatal Opioid Withdrawal Syndrome: A Comparison of As-Needed Pharmacotherapy. Hosp Pediatr 2022; 12:530-538. [PMID: 35403199 DOI: 10.1542/hpeds.2021-006301] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVE Methadone and morphine are commonly administered medications for neonatal opioid withdrawal syndrome (NOWS). Infants are increasingly treated with as-needed or "pro re nata" (PRN) medication. The optimal pharmacologic agent for PRN treatment of NOWS has not been examined. This study's objective is to compare NOWS hospital outcomes between infants treated with PRN methadone versus morphine. METHODS We performed a retrospective cohort study of infants pharmacologically treated for NOWS across 4 Massachusetts hospitals between January 2018 and February 2021. Infants born ≥36 weeks gestation with prenatal opioid exposure treated with PRN methadone or morphine were included. Mixed effects logistic and linear regression models were employed to evaluate differences in transition rates to scheduled dosing, length of stay, and number of PRN doses administered depending on PRN treatment agent. RESULTS There were 86 infants in the methadone group and 52 in the morphine group. There were no significant differences in NOWS hospital outcomes between groups in adjusted models: transition to scheduled dosing (methadone 31.6% vs morphine 28.6%, adjusted odds ratio 1.21, 95% confidence interval [CI] 0.87-1.19), mean length of stay (methadone 15.5 vs morphine 14.3 days, adjusted risk ratio 1.06, 95% CI 0.80-1.41), and the mean number of PRN doses (methadone 2.3 vs morphine 3.4, adjusted risk ratio 0.65, 95% CI 0.41-1.02). There was an association with nonpharmacologic care practices and improved NOWS hospital outcomes. CONCLUSIONS There were no significant differences in NOWS hospitalization outcomes based on pharmacologic agent type; nonpharmacologic care practices were most strongly associated with improved NOWS hospitalization outcomes.
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Affiliation(s)
| | | | - Patrice Melvin
- Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston, Massachusetts
| | - Rachana Singh
- Department of Pediatrics, Tufts Children's Hospital, Boston, Massachusetts
| | - Jennifer Murzycki
- Department of Newborn Medicine, Lowell General Hospital, Lowell, Massachusetts
| | - Marcia W Van Vleet
- Department of Newborn Medicine, Baystate Franklin Medical Center, Greenfield, Massachusetts
| | - Robert Rothstein
- Department of Pediatrics, Baystate Medical Center, Springfield, Massachusetts
| | | | - Munish Gupta
- Department of Newborn Medicine, Beth Israel Hospital, Boston, Massachusetts
| | - Davida M Schiff
- Department of Pediatrics, MassGen Hospital for Children, Boston, Massachusetts
| | - Elisha M Wachman
- Department of Pediatrics, Boston Medical Center, Boston, Massachusetts
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15
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Rana D, Garde K, Elabiad MT, Pourcyrous M. Whole body massage for newborns: A report on non-invasive methodology for neonatal opioid withdrawal syndrome. J Neonatal Perinatal Med 2022; 15:559-565. [PMID: 35599503 DOI: 10.3233/npm-220989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Infants with in-utero exposure to opioids are at risk Neonatal Opioid Withdrawal Syndrome (NOWS) and non-pharmacological methods of care, like swaddling, quiet ambient environment are routinely recommended but are not systematically studied. We hypothesized that opioid exposed infants can tolerate whole body massage while hospitalized. METHODS This is a prospective observational study (August 2017 to January 2019) and infants of mothers having a history of opioids use (OUD) were included. Infants received whole body massage for 30 minutes from birth till discharge home. Infants heart rate (HR), respiratory rate (RR), systolic (sBP) and diastolic blood pressure (dBP) were recorded prior to and at the end of massage session. RESULTS The pilot study enrolled 30 infants. The mean birth weight and gestational age were 38±1 weeks and 2868±523 grams, respectively. All massage sessions were well tolerated. There was marked decrease in HR, systolic and diastolic BP and RR, (p < 0.01) in all study infants post massage, more profound among infants with NOWS (p < 0.01) than without NOWS. CONCLUSIONS Whole body massage is very well tolerated by infants with in-utero opioid exposure. Infants with NOWS had marked decrease in their HR and BP from their baseline after massage.
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Affiliation(s)
- D Rana
- Departments of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - K Garde
- Department of Rehabilitation, Regional One Health, Memphis, TN, USA
| | - M T Elabiad
- Departments of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - M Pourcyrous
- Departments of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
- Obstetrics & Gynecology, University of Tennessee Health Science Center, Memphis, TN, USA
- Physiology, University of Tennessee Health Science Center, Memphis, TN, USA
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Oni HT, Buultjens M, Mohamed AL, Islam MM. Neonatal Outcomes of Infants Born to Pregnant Women With Substance Use Disorders: A Multilevel Analysis of Linked Data. Subst Use Misuse 2022; 57:1-10. [PMID: 34369268 DOI: 10.1080/10826084.2021.1958851] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE This study examines the associations of substance use disorders in pregnancy with a set of neonatal outcomes. METHODS This is a quantitative retrospective study. Three linked datasets of a 10-year period (2007-2016) from New South Wales, Australia, were examined. Pregnant women were identified positive for substance use disorders when at least one hospital admission during pregnancy or delivery had opioid-, or cannabis-, or stimulant-, or alcohol- or two or more of the four substance groups- related ICD-10-AM diagnostic code. As there was a hierarchical structure in the dataset, the adjusted odds ratio (AOR) was estimated using multilevel logistic regression. FINDINGS Of the 622,640 birth records, 1677 (0.27%) women had opioid-related, 1857 (0.30%) had cannabis-related, 552 (0.09%) had stimulant-related, 595 (0.10%) had alcohol-related and 591 (0.09%) had polysubstance-related ICD-10-AM diagnostic codes. There were significant relationships between opioid use in pregnancy and neonatal health outcomes including preterm birth (AOR 3.2; 95% CI 2.8, 3.7) and admission to the neonatal intensive care unit (NICU) (AOR 10.0; 95% CI 8.8, 11.3). Substance use disorders due to cannabis, stimulants, alcohol or polysubstance were significantly associated with preterm birth, low birthweight, low APGAR score and admission to NICU. Also, alcohol and polysubstance use disorders in pregnancy were found to be significantly associated with stillbirth. CONCLUSION Results demonstrate that substance use disorders in pregnancy are associated with an increased risk of adverse neonatal outcomes. Early identification of substance use disorders through screening and adherence to pharmacotherapy and other psychosocial interventions could improve neonatal outcomes.
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Affiliation(s)
- Helen T Oni
- Department of Public Health, La Trobe University, Bundoora, VIC, Australia
| | - Melissa Buultjens
- Department of Public Health, La Trobe University, Bundoora, VIC, Australia
| | - Abdel-Latif Mohamed
- Department of Public Health, La Trobe University, Bundoora, VIC, Australia.,Canberra Hospital, Canberra Hospital, Garran, ACT, Australia
| | - M Mofizul Islam
- Department of Public Health, La Trobe University, Bundoora, VIC, Australia
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17
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López-Soto D, Griffin PM. Estimating the impact of neonatal abstinence system interventions on Medicaid: an incremental cost analysis. Subst Abuse Treat Prev Policy 2021; 16:91. [PMID: 34930347 PMCID: PMC8691068 DOI: 10.1186/s13011-021-00427-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2021] [Indexed: 11/15/2022] Open
Abstract
Background Neonatal abstinence syndrome (NAS) incidence has significantly increased in the US in recent years. It is therefore important to develop effective intervention protocols that mitigate the long-term consequences of this condition for the mother, her child, and the community. Methods We used Monte Carlo simulation to estimate the impact of four interventions for NAS and their combinations on pregnant women with opioid use disorder. The key outputs were changes in incremental costs from baseline from the Medicaid perspective and from a total systems perspective and effect size changes. Simulation parameters and costs were based on the literature and baseline model validation was performed using Medicaid claims for Indiana. Results Compared to baseline, the resulting simulation estimates showed that three interventions significantly decreased Medicaid incremental costs by 8% (mandatory opioid testing (MOT)), 4% (patient navigators), and 3% (peer recovery coaches). The combination of the three interventions reduced Medicaid direct costs by 26%. Reductions were similar for total system incremental costs (ranging from 2 to 24%), though MOT was found to increase costs of overdose death based on productivity loss. NAS case reductions ranged from 1% (capacity change) to 13% (MOT). Conclusions Using systems-based modeling, we showed that costs associated with NAS can be significantly reduced. However, effective implementation would require the involvement and coordination of several stakeholders. In addition, careful protocols for MOT should be considered to ensure pregnant women don’t forgo prenatal care for fear of punitive consequences. Supplementary Information The online version contains supplementary material available at 10.1186/s13011-021-00427-1.
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van Hoogdalem MW, Wexelblatt SL, Akinbi HT, Vinks AA, Mizuno T. A review of pregnancy-induced changes in opioid pharmacokinetics, placental transfer, and fetal exposure: Towards fetomaternal physiologically-based pharmacokinetic modeling to improve the treatment of neonatal opioid withdrawal syndrome. Pharmacol Ther 2021; 234:108045. [PMID: 34813863 DOI: 10.1016/j.pharmthera.2021.108045] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 10/29/2021] [Accepted: 11/15/2021] [Indexed: 02/07/2023]
Abstract
Physiologically-based pharmacokinetic (PBPK) modeling has emerged as a useful tool to study pharmacokinetics (PK) in special populations, such as pregnant women, fetuses, and newborns, where practical hurdles severely limit the study of drug behavior. PK in pregnant women is variable and everchanging, differing greatly from that in their nonpregnant female and male counterparts typically enrolled in clinical trials. PBPK models can accommodate pregnancy-induced physiological and metabolic changes, thereby providing mechanistic insights into maternal drug disposition and fetal exposure. Fueled by the soaring opioid epidemic in the United States, opioid use during pregnancy continues to rise, leading to an increased incidence of neonatal opioid withdrawal syndrome (NOWS). The severity of NOWS is influenced by a complex interplay of extrinsic and intrinsic factors, and varies substantially between newborns, but the extent of prenatal opioid exposure is likely the primary driver. Fetomaternal PBPK modeling is an attractive approach to predict in utero opioid exposure. To facilitate the development of fetomaternal PBPK models of opioids, this review provides a detailed overview of pregnancy-induced changes affecting the PK of commonly used opioids during gestation. Moreover, the placental transfer of these opioids is described, along with their disposition in the fetus. Lastly, the implementation of these factors into PBPK models is discussed. Fetomaternal PBPK modeling of opioids is expected to provide improved insights in fetal opioid exposure, which allows for prediction of postnatal NOWS severity, thereby opening the way for precision postnatal treatment of these vulnerable infants.
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Affiliation(s)
- Matthijs W van Hoogdalem
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH, USA
| | - Scott L Wexelblatt
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA; Center for Addiction Research, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Henry T Akinbi
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA; Center for Addiction Research, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA; Center for Addiction Research, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.
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19
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Shuman CJ, Wilson R, VanAntwerp K, Morgan M, Weber A. Elucidating the context for implementing nonpharmacologic care for neonatal opioid withdrawal syndrome: a qualitative study of perinatal nurses. BMC Pediatr 2021; 21:489. [PMID: 34736443 PMCID: PMC8567648 DOI: 10.1186/s12887-021-02955-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 10/15/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Up to 95% of neonates exposed to opioids in utero experience neonatal opioid withdrawal syndrome at birth. Nonpharmacologic approaches (e.g., breastfeeding; rooming-in; skin-to-skin care) are evidence-based and should be implemented. These approaches, especially breastfeeding, rely on engagement of the neonates' mothers to help deliver them. However, little is known about the structural and social dynamic context barriers and facilitators to implementing maternal-delivered nonpharmacologic care. METHODS Using a qualitative descriptive design, perinatal nurses from a Midwest United States hospital family birthing center, neonatal intensive care unit, and inpatient pediatric unit were interviewed. These units were involved in caring for mothers and neonates affected by opioid use. Telephone interviews followed a semi-structured interview guide developed for this study, were audio-recorded, and lasted about 30-60 min. Interviews were transcribed verbatim and independently analyzed by five investigators using the constant comparative method. Themes were discussed until reaching consensus and subsequently mapped to a conceptual model adapted for this study. RESULTS Twenty-one nurses participated in this study (family birth center, n = 9; neonatal intensive care, n = 6; pediatrics, n = 6). Analysis resulted in four major themes: 1) Lack of education and resources provided to staff and mothers; 2) Importance of interdisciplinary and intradisciplinary care coordination; 3) Flexibility in nurse staffing models for neonatal opioid withdrawal syndrome; and 4) Unit architecture and layout affects maternal involvement. Minor themes supported each of the four major themes. All themes mapped to the conceptual model. CONCLUSIONS This study provides a more comprehensive understanding of the barriers and facilitators affecting implementation of maternal involvement in nonpharmacologic care of newborns with neonatal opioid withdrawal syndrome. Future efforts implementing nonpharmacologic approaches must consider the context factors affecting implementation, including structural and social factors within the units, hospital, and broader community.
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Affiliation(s)
- Clayton J Shuman
- School of Nursing, University of Michigan, 400 N. Ingalls, Ste. 4162, Ann Arbor, MI, USA.
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
- Center for the Study of Drugs, Alcohol, Smoking, and Health, University of Michigan, Ann Arbor, MI, USA.
| | - Roxanne Wilson
- Department of Nursing, St. Cloud State University, St. Cloud, MN, USA
- St. Cloud Hospital, St. Cloud, MN, USA
| | - Katherine VanAntwerp
- School of Nursing, University of Michigan, 400 N. Ingalls, Ste. 4162, Ann Arbor, MI, USA
| | - Mikayla Morgan
- School of Nursing, University of Michigan, 400 N. Ingalls, Ste. 4162, Ann Arbor, MI, USA
| | - Ashley Weber
- College of Nursing, University of Cincinnati, Cincinnati, OH, USA
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20
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Abstract
Supplemental digital content is available in the text. Background Neonatal abstinence syndrome (NAS) rates have dramatically increased. Breastfeeding is a nonpharmacological intervention that may be beneficial, reducing NAS symptom severity and thus the need for and duration of pharmacological treatment and length of hospital stay. Objectives Conduct meta-analysis to determine whether breastfeeding results in better outcomes for NAS infants. Variables included symptom severity, need for and duration of pharmacological treatment, and length of hospital stay. Methods PubMed, Scopus, Embase, and Cochrane Library were searched from 2000 to 2020, and comparative studies examining breastfeeding for NAS infants were extracted. Randomized trials and cohort studies were included. Data were extracted and evaluated with Review Manager Version 5.3. A random-effects model was used to pool discontinuous outcomes using risk ratio and 95% confidence intervals. Continuous outcomes were evaluated by mean differences and 95% confidence intervals. Results Across 11 studies, 6,375 neonates were included in the meta-analysis. Using a random-effects analysis, breastfeeding reduced initiation of pharmacological treatment, reduced duration of pharmacological treatment, and reduced length of stay. No differences were detected for severity of NAS symptoms. Most studies only reported one to two variables of interest. For most studies, these variables were not the primary study outcomes. All studies were found to be of low risk and good quality based on the Cochrane Risk Assessment Tools. Varying breastfeeding definitions limit generalizability. Discussion Breastfeeding is associated with decreased initiation and duration of pharmacological treatment and length of stay.
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21
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Borrelli KN, Yao EJ, Yen WW, Phadke RA, Ruan QT, Chen MM, Kelliher JC, Langan CR, Scotellaro JL, Babbs RK, Beierle JC, Logan RW, Johnson WE, Wachman EM, Cruz-Martín A, Bryant CD. Sex Differences in Behavioral and Brainstem Transcriptomic Neuroadaptations following Neonatal Opioid Exposure in Outbred Mice. eNeuro 2021; 8:ENEURO.0143-21.2021. [PMID: 34479978 PMCID: PMC8454922 DOI: 10.1523/eneuro.0143-21.2021] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/02/2021] [Accepted: 08/25/2021] [Indexed: 12/13/2022] Open
Abstract
The opioid epidemic led to an increase in the number of neonatal opioid withdrawal syndrome (NOWS) cases in infants born to opioid-dependent mothers. Hallmark features of NOWS include weight loss, severe irritability, respiratory problems, and sleep fragmentation. Mouse models provide an opportunity to identify brain mechanisms that contribute to NOWS. Neonatal outbred Swiss Webster Cartworth Farms White (CFW) mice were administered morphine (15 mg/kg, s.c.) twice daily from postnatal day 1 (P1) to P14, an approximation of the third trimester of human gestation. Female and male mice underwent behavioral testing on P7 and P14 to determine the impact of opioid exposure on anxiety and pain sensitivity. Ultrasonic vocalizations (USVs) and daily body weights were also recorded. Brainstems containing pons and medulla were collected during morphine withdrawal on P14 for RNA sequencing. Morphine induced weight loss from P2 to P14, which persisted during adolescence (P21) and adulthood (P50). USVs markedly increased at P7 in females, emerging earlier than males. On P7 and P14, both morphine-exposed female and male mice displayed hyperalgesia on the hot plate and tail-flick assays, with females showing greater hyperalgesia than males. Morphine-exposed mice exhibited increased anxiety-like behavior in the open-field arena on P21. Transcriptome analysis of the brainstem, an area implicated in opioid withdrawal and NOWS, identified pathways enriched for noradrenergic signaling in females and males. We also found sex-specific pathways related to mitochondrial function and neurodevelopment in females and circadian entrainment in males. Sex-specific transcriptomic neuroadaptations implicate unique neurobiological mechanisms underlying NOWS-like behaviors.
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Affiliation(s)
- Kristyn N Borrelli
- Laboratory of Addiction Genetics, Departments of Pharmacology and Experimental Therapeutics and Psychiatry, Boston University School of Medicine, Boston, Massachusetts 02118
- Graduate Program for Neuroscience, Boston University, Boston, Massachusetts 02118
- Transformative Training Program in Addiction Science, Boston University, Boston, Massachusetts 02118
- NIGMS Training Program in Biomolecular Pharmacology, Boston University School of Medicine, Boston, Massachusetts 02118
| | - Emily J Yao
- Laboratory of Addiction Genetics, Departments of Pharmacology and Experimental Therapeutics and Psychiatry, Boston University School of Medicine, Boston, Massachusetts 02118
| | - William W Yen
- Neurobiology Section, Department of Biology, Boston University, Boston, Massachusetts 02215
| | - Rhushikesh A Phadke
- Neurobiology Section, Department of Biology, Boston University, Boston, Massachusetts 02215
- Molecular Biology, Cell Biology, and Biochemistry (MCBB), Boston University, Boston, Massachusetts 02215
| | - Qiu T Ruan
- Laboratory of Addiction Genetics, Departments of Pharmacology and Experimental Therapeutics and Psychiatry, Boston University School of Medicine, Boston, Massachusetts 02118
- Transformative Training Program in Addiction Science, Boston University, Boston, Massachusetts 02118
- NIGMS Training Program in Biomolecular Pharmacology, Boston University School of Medicine, Boston, Massachusetts 02118
| | - Melanie M Chen
- Laboratory of Addiction Genetics, Departments of Pharmacology and Experimental Therapeutics and Psychiatry, Boston University School of Medicine, Boston, Massachusetts 02118
| | - Julia C Kelliher
- Laboratory of Addiction Genetics, Departments of Pharmacology and Experimental Therapeutics and Psychiatry, Boston University School of Medicine, Boston, Massachusetts 02118
| | - Carly R Langan
- Laboratory of Addiction Genetics, Departments of Pharmacology and Experimental Therapeutics and Psychiatry, Boston University School of Medicine, Boston, Massachusetts 02118
| | - Julia L Scotellaro
- Laboratory of Addiction Genetics, Departments of Pharmacology and Experimental Therapeutics and Psychiatry, Boston University School of Medicine, Boston, Massachusetts 02118
- Undergraduate Research Opportunity Program, Boston University, Boston, Massachusetts 02118
| | - Richard K Babbs
- Laboratory of Addiction Genetics, Departments of Pharmacology and Experimental Therapeutics and Psychiatry, Boston University School of Medicine, Boston, Massachusetts 02118
| | - Jacob C Beierle
- Laboratory of Addiction Genetics, Departments of Pharmacology and Experimental Therapeutics and Psychiatry, Boston University School of Medicine, Boston, Massachusetts 02118
- Transformative Training Program in Addiction Science, Boston University, Boston, Massachusetts 02118
- NIGMS Training Program in Biomolecular Pharmacology, Boston University School of Medicine, Boston, Massachusetts 02118
| | - Ryan W Logan
- Laboratory of Sleep, Rhythms, and Addiction, Department of Pharmacology and Experimental Therapeutics, Boston University School of Medicine, Boston, Massachusetts 02118
- Center for Systems Neurogenetics of Addiction, The Jackson Laboratory, Bar Harbor, Maine 04609
| | - William Evan Johnson
- Department of Medicine, Computational Biomedicine, Boston University School of Medicine, Boston, Massachusetts 02118
| | - Elisha M Wachman
- Department of Pediatrics, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts 02118
| | - Alberto Cruz-Martín
- Neurobiology Section, Department of Biology, Boston University, Boston, Massachusetts 02215
| | - Camron D Bryant
- Laboratory of Addiction Genetics, Departments of Pharmacology and Experimental Therapeutics and Psychiatry, Boston University School of Medicine, Boston, Massachusetts 02118
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22
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Fan JN, Sharma A. Lessons Learned From Helplessness: Reflections Volunteering as a "Cuddler". J Grad Med Educ 2021; 13:585-586. [PMID: 34434522 PMCID: PMC8370367 DOI: 10.4300/jgme-d-20-01343.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Jennifer Nielsen Fan
- Both authors are with Baylor Scott and White Medical Center-Round Rock
- is a Resident, Department of Family Medicine
| | - Anuj Sharma
- Both authors are with Baylor Scott and White Medical Center-Round Rock
- is Family Medicine Core Faculty, Department of Family Medicine
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23
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Goodstein MH, Stewart DL, Keels EL, Moon RY. Transition to a Safe Home Sleep Environment for the NICU Patient. Pediatrics 2021; 148:peds.2021-052045. [PMID: 34155134 DOI: 10.1542/peds.2021-052045] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Of the nearly 3.8 million infants born in the United States in 2018, 8.3% had low birth weight (ie, weight <2500 g) and 10% were born preterm (ie, gestational age of <37 weeks). Ten to fifteen percent of infants (approximately 500 000 annually), including low birth weight and preterm infants and others with congenital anomalies, perinatally acquired infections, and other diseases, require admission to a NICU. Every year, approximately 3600 infants in the United States die of sudden unexpected infant death (SUID), including sudden infant death syndrome (SIDS), unknown and undetermined causes, and accidental suffocation and strangulation in an unsafe sleep environment. Preterm and low birth weight infants are 2 to 3 times more likely than healthy term infants to die suddenly and unexpectedly. Thus, it is important that health care professionals prepare families to maintain their infant in a safe home sleep environment as per recommendations of the American Academy of Pediatrics. Medical needs of the NICU infant often require practices such as nonsupine positioning, which should be transitioned as soon as medically possible and well before hospital discharge to sleep practices that are safe and appropriate for the home environment. This clinical report outlines the establishment of appropriate NICU protocols for the timely transition of these infants to a safe home sleep environment. The rationale for these recommendations is discussed in the accompanying technical report "Transition to a Safe Home Sleep Environment for the NICU Patient," included in this issue of Pediatrics.
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Affiliation(s)
- Michael H Goodstein
- Division of Newborn Services, WellSpan Health, York, Pennsylvania .,Department of Pediatrics, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania
| | - Dan L Stewart
- Department of Pediatrics, Norton Children's and School of Medicine, University of Louisville, Louisville, Kentucky
| | - Erin L Keels
- National Association of Neonatal Nurse Practitioners, National Association of Neonatal Nurses, Chicago, Illinois.,Neonatal Advanced Practice, Nationwide Children's Hospital, Columbus, Ohio
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24
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Goodstein MH, Stewart DL, Keels EL, Moon RY. Transition to a Safe Home Sleep Environment for the NICU Patient. Pediatrics 2021; 148:peds.2021-052046. [PMID: 34155135 DOI: 10.1542/peds.2021-052046] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Of the nearly 3.8 million infants born in the United States in 2018, 8.3% had low birth weight (<2500 g [5.5 lb]) and 10% were born preterm (gestational age of <37 completed weeks). Many of these infants and others with congenital anomalies, perinatally acquired infections, and other disease require admission to a NICU. In the past decade, admission rates to NICUs have been increasing; it is estimated that between 10% and 15% of infants will spend time in a NICU, representing approximately 500 000 neonates annually. Approximately 3600 infants die annually in the United States from sleep-related deaths, including sudden infant death syndrome International Classification of Diseases, 10th Revision (R95), ill-defined deaths (R99), and accidental suffocation and strangulation in bed (W75). Preterm and low birth weight infants are particularly vulnerable, with an incidence of death 2 to 3 times greater than healthy term infants. Thus, it is important for health care professionals to prepare families to maintain their infant in a safe sleep environment, as per the recommendations of the American Academy of Pediatrics. However, infants in the NICU setting commonly require care that is inconsistent with infant sleep safety recommendations. The conflicting needs of the NICU infant with the necessity to provide a safe sleep environment before hospital discharge can create confusion for providers and distress for families. This technical report is intended to assist in the establishment of appropriate NICU protocols to achieve a consistent approach to transitioning NICU infants to a safe sleep environment as soon as medically possible, well before hospital discharge.
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Affiliation(s)
- Michael H Goodstein
- Division of Newborn Services, WellSpan Health, York, Pennsylvania .,Department of Pediatrics, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania
| | - Dan L Stewart
- Department of Pediatrics, Norton Children's and School of Medicine, University of Louisville, Louisville, Kentucky
| | - Erin L Keels
- National Association of Neonatal Nurse Practitioners, National Association of Neonatal Nurses, Chicago, Illinois.,Neonatal Advanced Practice, Nationwide Children's Hospital, Columbus, Ohio
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Abstract
OBJECTIVES To study the impact of sociodemographic factors on length of stay (LOS) for infants with neonatal opioid withdrawal syndrome (NOWS) secondary to fetal opioid exposure. METHODS In this retrospective cohort study, we included term infants with NOWS, excluding those with other significant medical issues. Comprehensive clinical and sociodemographic data were collected. Multivariate regression modeling was used to identify factors which contributed to excess LOS, which was defined as the number of days beyond the standard monitoring and/or treatment protocol. RESULTS In all, 129 infants were identified; mean gestational age of 37.9 ± 1.3 weeks and mean body weight of 2880 ± 496 g. Among them, 68% of infants were exposed to opioids; 27% were exposed to methadone; and 67% required pharmacologic treatment. The degree of poverty was assessed using the Area Deprivation Index (ADI) based on the mother's address at the time of birth. Median LOS for treated infants was 23 days versus 8 days for those who did not need pharmacologic treatment. The median excess LOS was 4 days (range 0-24).Excess hospital days were strongly correlated with degree of deprivation in the mother's community (r = 0.55, P < 0.01). ADI remained a strong predictor of excess LOS, even when controlling for pharmacologic treatment, placement in state's custody, race, and gestational age at birth. CONCLUSIONS These results suggest poverty is associated with excess LOS and that early allocation of resources for at-risk families may help to reduce overall length of hospital stay.
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26
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Coulson CC, Lorencz E, Rittenhouse K, Ramage M, Lorenz K, Galvin SL. Association of Maternal Buprenorphine or Methadone Dose with Fetal Growth Indices and Neonatal Abstinence Syndrome. Am J Perinatol 2021; 38:28-36. [PMID: 31421639 DOI: 10.1055/s-0039-1694729] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Our objective was to compare fetal growth and incidence of neonatal abstinence syndrome requiring treatment across pregnant women with opioid use disorders on two types and two dose categories of medication-assisted treatment. STUDY DESIGN A retrospective cohort study was conducted in a comprehensive, perinatal program in western North Carolina comparing growth percentiles on third-trimester ultrasound and at birth, and diagnosis of neonatal abstinence syndrome requiring treatment. Singletons were exposed in utero to low- to moderate-dose buprenorphine (≤16 mg/day; n = 70), high-dose buprenorphine (≥17 mg/day; n = 36), low- to moderate-dose methadone (≤89 mg/day; n = 41), or high-dose methadone (≥90 mg/day; n = 74). Multivariate analysis of variance with posthoc Bonferroni comparisons (p ≤ 0.01) and multinomial logistic regressions (adjusted odds ratio, 99% confidence interval) were conducted. RESULTS Differences in neonatal outcomes reached statistical significance for larger head circumference for buprenorphine doses (p = 0.01) and for longer length (p < 0.01) and lower odds of neonatal abstinence syndrome requiring treatment (p < 0.01) with low- to moderate-dose buprenorphine versus high-dose methadone. CONCLUSION Among pregnant women using medication-assisted treatment for opioid use disorders, low- to moderate-dose buprenorphine (≤16 mg/day) was associated with the most favorable neonatal outcomes. However, more rigorous control of confounders with a larger sample is necessary to determine if low- to moderate-dose buprenorphine is the better treatment choice.
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Affiliation(s)
- Carol C Coulson
- Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina.,Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Erin Lorencz
- Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina
| | - Katelyn Rittenhouse
- University of North Carolina School of Medicine-Asheville, Asheville, North Carolina
| | - Melinda Ramage
- Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina
| | - Kathleen Lorenz
- Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina
| | - Shelley L Galvin
- Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina.,Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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27
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Pahl A, Young L, Buus-Frank ME, Marcellus L, Soll R. Non-pharmacological care for opioid withdrawal in newborns. Cochrane Database Syst Rev 2020; 12:CD013217. [PMID: 33348423 PMCID: PMC8130993 DOI: 10.1002/14651858.cd013217.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The prevalence of substance use, both prescribed and non-prescribed, is increasing in many areas of the world. Substance use by women of childbearing age contributes to increasing rates of neonatal abstinence syndrome (NAS). Neonatal opioid withdrawal syndrome (NOWS) is a newer term describing the subset of NAS related to opioid exposure. Non-pharmacological care is the first-line treatment for substance withdrawal in newborns. Despite the widespread use of non-pharmacological care to mitigate symptoms of NAS, there is not an established definition of, and standard for, non-pharmacological care practices in this population. Evaluation of safety and efficacy of non-pharmacological practices could provide clear guidance for clinical practice. OBJECTIVES To evaluate the safety and efficacy of non-pharmacological treatment of infants at risk for, or having symptoms consistent with, opioid withdrawal on the length of hospitalization and use of pharmacological treatment for symptom management. Comparison 1: in infants at risk for, or having early symptoms consistent with, opioid withdrawal, does non-pharmacological treatment reduce the length of hospitalization and use of pharmacological treatment? Comparison 2: in infants receiving pharmacological treatment for symptoms consistent with opioid withdrawal, does concurrent non-pharmacological treatment reduce duration of pharmacological treatment, maximum and cumulative doses of opioid medication, and length of hospitalization? SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search CENTRAL (2019, Issue 10); Ovid MEDLINE; and CINAHL on 11 October 2019. We also searched clinical trials databases and the reference lists of retrieved articles for randomized controlled trials (RCTs), quasi-RCTs, and cluster trials. SELECTION CRITERIA We included trials comparing single or bundled non-pharmacological interventions to no non-pharmacological treatment or different single or bundled non-pharmacological interventions. We assessed non-pharmacological interventions independently and in combination based on sufficient similarity in population, intervention, and comparison groups studied. We categorized non-pharmacological interventions as: modifying environmental stimulation, feeding practices, and support of the mother-infant dyad. We presented non-randomized studies identified in the search process narratively. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We used the GRADE approach to assess the certainty of evidence. Primary outcomes in infants at risk for, or having early symptoms consistent with, opioid withdrawal included length of hospitalization and pharmacological treatment with one or more doses of opioid or sedative medication. Primary outcomes in infants receiving opioid treatment for symptoms consistent with opioid withdrawal included length of hospitalization, length of pharmacological treatment with opioid or sedative medication, and maximum and cumulative doses of opioid medication. MAIN RESULTS We identified six RCTs (353 infants) in which infants at risk for, or having symptoms consistent with, opioid withdrawal participated between 1975 and 2018. We identified no RCTs in which infants receiving opioid treatment for symptoms consistent with opioid withdrawal participated. The certainty of evidence for all outcomes was very low to low. We also identified and excluded 34 non-randomized studies published between 2005 and 2018, including 29 in which infants at risk for, or having symptoms consistent with, opioid withdrawal participated and five in which infants receiving opioid treatment for symptoms consistent with opioid withdrawal participated. We identified seven preregistered interventional clinical trials that may qualify for inclusion at review update when complete. Of the six RCTs, four studies assessed modifying environmental stimulation in the form of a mechanical rocking bed, prone positioning, non-oscillating waterbed, or a low-stimulation nursery; one study assessed feeding practices (comparing 24 kcal/oz to 20 kcal/oz formula); and one study assessed support of the maternal-infant dyad (tailored breastfeeding support). There was no evidence of a difference in length of hospitalization in the one study that assessed modifying environmental stimulation (mean difference [MD) -1 day, 95% confidence interval [CI) -2.82 to 0.82; 30 infants; very low-certainty evidence) and the one study of support of the maternal-infant dyad (MD -8.9 days, 95% CI -19.84 to 2.04; 14 infants; very low-certainty evidence). No studies of feeding practices evaluated the length of hospitalization. There was no evidence of a difference in use of pharmacological treatment in three studies of modifying environmental stimulation (typical risk ratio [RR) 1.00, 95% CI 0.86 to 1.16; 92 infants; low-certainty evidence), one study of feeding practices (RR 0.92, 95% CI 0.63 to 1.33; 49 infants; very low-certainty evidence), and one study of support of the maternal-infant dyad (RR 0.50, 95% CI 0.13 to 1.90; 14 infants; very low-certainty evidence). Reported secondary outcomes included neonatal intensive care unit (NICU) admission, days to regain birth weight, and weight nadir. One study of support of the maternal-infant dyad reported NICU admission (RR 0.50, 95% CI 0.13 to 1.90; 14 infants; very low-certainty evidence). One study of feeding practices reported days to regain birth weight (MD 1.10 days, 95% CI 2.76 to 0.56; 46 infants; very low-certainty evidence). One study that assessed modifying environmental stimulation reported weight nadir (MD -0.28, 95% CI -1.15 to 0.59; 194 infants; very low-certainty evidence) and one study of feeding practices reported weight nadir (MD -0.8, 95% CI -2.24 to 0.64; 46 infants; very low-certainty evidence). AUTHORS' CONCLUSIONS We are uncertain whether non-pharmacological care for opioid withdrawal in newborns affects important clinical outcomes including length of hospitalization and use of pharmacological treatment based on the six included studies. The outcomes identified for this review were of very low- to low-certainty evidence. Combined analysis was limited by heterogeneity in study design and intervention definitions as well as the number of studies. Many prespecified outcomes were not reported. Although caregivers are encouraged by experts to optimize non-pharmacological care for opioid withdrawal in newborns prior to initiating pharmacological care, we do not have sufficient evidence to inform specific clinical practices. Larger well-designed studies are needed to determine the effect of non-pharmacological care for opioid withdrawal in newborns.
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Affiliation(s)
- Adrienne Pahl
- Pediatrics, University of Vermont Medical Center, Burlington, VT, USA
| | - Leslie Young
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Madge E Buus-Frank
- The Children's Hospital at Dartmouth, Lebanon, New Hampshire, USA
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire, USA
| | | | - Roger Soll
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
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Abstract
BACKGROUND There has been an increase in infants with neonatal abstinence syndrome (NAS) in neonatal intensive care units (NICUs) over the past several decades. Infants with NAS experience withdrawal as a result of the sudden termination at birth of substance exposure during pregnancy. A serious sign related to infants diagnosed with NAS is poor feeding. The prevalence of NAS urges researchers and clinicians to develop effective strategies and techniques to treat and manage the poor feeding of infants exposed to substances in utero. PURPOSE To synthesize current feeding methods and practices used for infants diagnosed with NAS. METHODS/SEARCH STRATEGY PubMed, CINAHL, and Scopus were searched for articles published within the last 20 years that focused on feeding practices or feeding schedules, were written in English, were peer-reviewed, and described human studies. The search terms utilized were "neonatal abstinence syndrome" OR "neonatal opioid withdrawal syndrome" AND "feeding." FINDINGS/RESULTS Three findings emerged regarding techniques and management of poor feeding in the NAS population. The findings included infants who received mother's own milk had decreased severity and later onset of clinical signs of withdrawal, demand feeding is recommended, and the infant's cues may be helpful to follow when feeding. IMPLICATIONS FOR PRACTICE Clinicians should encourage mother's own milk in this population unless contraindications are present. Caregivers and clinicians must be receptive to cues when feeding infants with NAS. IMPLICATIONS FOR RESEARCH Even with the clinical knowledge and experience that infants with NAS are difficult to feed, there is limited research assessing techniques and schedules that are effective in managing successful feeding. Future research should compare feeding schedules such as on-demand feeding versus regimented feeding schedules, as well as investigate techniques that mothers and nurses can utilize to encourage oral intake in this population.Video abstract available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=37.
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Tice H, Manzar S, Walyat N, Trimble K. Say no to drugs: wait and watch strategy for medications used in the neonatal intensive care unit (NICU). World J Pediatr 2020; 16:560-561. [PMID: 31748984 DOI: 10.1007/s12519-019-00323-6] [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: 09/13/2019] [Accepted: 11/01/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Hilary Tice
- University of Louisiana at Monroe, 1501 Kings Highway, Shreveport Campus, 1725 Claiborne Avenue, Shreveport, LA, 71103, USA
| | - Shabih Manzar
- Division of Neonatology, Louisiana State University Health Sciences Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Nitin Walyat
- Division of Neonatology, Louisiana State University Health Sciences Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Kelsey Trimble
- Department of Pharmacy, Ochsner - LSU Health Shreveport, 1541 Kings Highway, Shreveport, LA, 71103, USA
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A Mixed-Methods Study to Investigate Barriers and Enablers to Nurses' Implementation of Nonpharmacological Interventions for Infants With Neonatal Abstinence Syndrome. Adv Neonatal Care 2020; 20:450-463. [PMID: 33252500 DOI: 10.1097/anc.0000000000000794] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The incidence of neonatal abstinence syndrome has increased significantly as a result of the opioid epidemic. A lengthy hospitalization is often required to treat the infant's withdrawal symptoms. A comprehensive understanding of factors that influence nurses' implementation of nonpharmacological interventions for infants with neonatal abstinence syndrome is needed. PURPOSE To investigate barriers and enablers to nurses' implementation of nonpharmacological interventions for infants with neonatal abstinence syndrome through the lens of the Theoretical Domains Framework, which provides a structure to examine factors that influence healthcare providers' behavior related to the implementation of evidence-based practice and interventions in clinical practice. METHODS A convergent parallel mixed-methods study was conducted. Qualitative data were collected using semistructured interviews and quantitative data were collected using a tailored Determinants of Implementation Behavior Questionnaire with neonatal nurses. Findings from the interviews and surveys were merged through joint review to compare and contrast themes. RESULTS Enablers and barriers to nurses' implementation of nonpharmacological interventions included education, experience, ability to implement nonpharmacological interventions, parental participation, stigmatization, lack of managerial/organizational support, staffing ratios, internal and external resources, and stress. Knowledge, Skills, Beliefs About Capabilities, Social/Professional Role and Identity, Organization, and Emotion of the Theoretical Domains Framework aligned with these themes. IMPLICATIONS FOR PRACTICE AND RESEARCH Findings from this study will inform the development of programs to improve nurses' implementation of nonpharmacological interventions and health and utilization outcomes in infants with neonatal abstinence syndrome. Furthermore, future work should focus on the development of programs to improve nurses' implementation of nonpharmacological interventions, with specific strategies aimed to mitigate marginalization of vulnerable patient populations.
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Newman AI, Mauer-Vakil D, Coo H, Newton L, Wilkerson E, McKnight S, Brogly SB. Rooming-in for Infants at Risk for Neonatal Abstinence Syndrome: Outcomes 5 Years following Its Introduction as the Standard of Care at One Hospital. Am J Perinatol 2020; 39:897-903. [PMID: 33202425 PMCID: PMC9270102 DOI: 10.1055/s-0040-1719182] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The practice of rooming-in for opioid-dependent infants was introduced as the standard of care at our hospital following a pilot study which demonstrated that such infants had shorter lengths of stay and were less likely to require pharmacological treatment. We sought to determine whether these benefits have continued, and whether outcomes support continuing to use rooming-in as standard care. STUDY DESIGN Opioid-dependent infants delivered at 36 weeks gestation or later between January 1, 2015, and December 31, 2019, were eligible for rooming-in. Charts were reviewed and data were extracted regarding maternal and infant conditions, whether neonatal pharmacological treatment was required, and total length of hospital stay. Outcomes were compared with two historical groups reported in a previous pilot study: 24 healthy near-term opioid-dependent newborns who were admitted directly to the neonatal intensive care unit (NICU) prior to the introduction of rooming-in (May 1, 2012-May 31, 2013), and 20 similar opioid-dependent infants who were the first to room-in at our hospital (September 1, 2013-September 30, 2014). RESULTS Only 3.5% of 57 infants who roomed-in during the 5-year study period required pharmacological treatment, compared with 15% who roomed-in during the first year of the program's introduction and 83.3% who had been admitted directly to the NICU. The median length of stay remained 5 days for infants rooming-in, compared with 24 days for opioid-dependent infants in the cohort admitted to the NICU. CONCLUSION Early observations of the benefits of rooming-in on neonatal outcomes were sustained. Infants allowed to room-in were significantly less likely to require initiation of pharmacotherapy and a prolonged hospital stay than similar infants prior to the implementation of rooming-in as standard care. A large proportion of the infants who might have benefited from rooming-in required admission to the NICU for reasons other than neonatal abstinence syndrome (NAS). KEY POINTS · Benefits of rooming-in for near-term opioid-dependent infants were sustained or increased.. · Rooming-in is sustainable as standard care for these newborns.. · Many infants required admission to NICU for reasons other than NAS..
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Affiliation(s)
- Adam Isaiah Newman
- Department of Family Medicine, Queen's University, Kingston, Ontario, Canada,Department of Pediatrics, Queen's University, Kingston, Ontario, Canada,Address for correspondence Adam Isaiah Newman, MD Kingston Health Sciences Centre (Kingston General site), 76 Stuart StreetKingston, ON K7L 2V7Canada
| | - Dane Mauer-Vakil
- Health Services Research Program, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Helen Coo
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada
| | - Lynn Newton
- Department of Family Medicine, Queen's University, Kingston, Ontario, Canada,Department of Pediatrics, Queen's University, Kingston, Ontario, Canada,Women's and Children's Program, Kingston Health Sciences Centre, Kingston, Ontario, Canada,School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Emily Wilkerson
- School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Sarah McKnight
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada
| | - Susan B. Brogly
- Department of Surgery, Queen's University, Kingston, Ontario, Canada
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Abstract
PURPOSE OF REVIEW Perinatal opioid use is a major public health problem and is associated with a number of deleterious maternal and fetal effects. We review recent evidence of perinatal outcomes and treatment of opioid use disorder (OUD) during pregnancy. RECENT FINDINGS Opioid exposure in pregnancy is associated with multiple obstetric and neonatal adverse outcomes, with the most common being neonatal opioid withdrawal syndrome (NOWS). Treatment with buprenorphine or methadone is associated with NOWS, but neither medication appears to have significant adverse effects on early childhood development. Buprenorphine appears to be superior to methadone in terms of incidence and severity of NOWS in exposed infants. The long-term effects of opioid exposure in utero have been inconclusive, but recent longitudinal studies point to potential differences in brain morphology that may increase vulnerability to future stressors. Maintenance therapy with methadone or buprenorphine remains the standard of care for pregnant women with OUD given its consistent superiority to placebo in terms of rates of illicit drug use and pregnancy outcomes. New non-pharmacologic management options for NOWS appear promising. Future research is needed to further evaluate the effects of opioid exposure in utero and determine the optimal delivery model for maintenance therapy.
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Affiliation(s)
- Amalia Londono Tobon
- Department of Psychiatry, Yale School of Medicine, 40 Temple Street, Suite 6B, New Haven, CT, 06510, USA
| | - Erin Habecker
- Department of Psychiatry, Yale School of Medicine, 40 Temple Street, Suite 6B, New Haven, CT, 06510, USA
| | - Ariadna Forray
- Department of Psychiatry, Yale School of Medicine, 40 Temple Street, Suite 6B, New Haven, CT, 06510, USA.
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33
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van Donge T, Samiee‐Zafarghandy S, Pfister M, Koch G, Kalani M, Bordbar A, van den Anker J. Methadone dosing strategies in preterm neonates can be simplified. Br J Clin Pharmacol 2019; 85:1348-1356. [PMID: 30805946 PMCID: PMC6533437 DOI: 10.1111/bcp.13906] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 02/14/2019] [Accepted: 02/21/2019] [Indexed: 01/11/2023] Open
Abstract
AIMS A dramatic increase in newborn infants with neonatal abstinence syndrome has been observed and these neonates are frequently treated with complex methadone dosing schemes to control their withdrawal symptoms. Despite its abundant use, hardly any data on the pharmacokinetics (PK) of methadone is available in preterm neonates. Therefore we investigated developmental PK of methadone and evaluated current dosing strategies and possible simplification in this vulnerable population. METHODS A single-centre open-label prospective study was performed to collect PK data after a single oral dose of methadone in preterm neonates. A population PK model was built to characterize developmental PK of (R)- and (S)-methadone. Model-based simulations were performed to identify a simplified dosing strategy to reach and maintain target methadone exposure. RESULTS A total of 121 methadone concentrations were collected from 31 preterm neonates. A one-compartment model with first order absorption and elimination kinetics best described PK data for (R)- and (S)-methadone. Clearance increases with advancing gestational age and differs between R- and S-enantiomer, being slightly higher for the former (0.244 vs 0.167 L/h). Preterm neonates reached target exposure after 48 hours with currently used dosing schedules. Output from simulations revealed that target exposures can be achieved with a simplified dosing strategy during the first 4 days of treatment. CONCLUSION Methadone clearance in preterm neonates increases with advancing gestational age and its disposition is influenced by its chirality. Simulations that account for developmental PK changes indicate a shorter methadone dosing strategy can maintain target exposure to control withdrawal symptoms.
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Affiliation(s)
- Tamara van Donge
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital BaselUniversity of BaselBaselSwitzerland
| | | | - Marc Pfister
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital BaselUniversity of BaselBaselSwitzerland
- Certara LPPrincetonNJUSA
| | - Gilbert Koch
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital BaselUniversity of BaselBaselSwitzerland
| | - Majid Kalani
- Department of Pediatrics, Shahid Akbarabadi HospitalIran University of Medical SciencesTehranIran
| | - Arash Bordbar
- Department of Pediatrics, Shahid Akbarabadi HospitalIran University of Medical SciencesTehranIran
| | - John van den Anker
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital BaselUniversity of BaselBaselSwitzerland
- Intensive Care and Department of Pediatric SurgeryErasmus MC‐Sophia Children's HospitalRotterdamThe Netherlands
- Division of Clinical PharmacologyChildren's National Health SystemWashingtonDCUSA
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Jones HE, Kraft WK. Analgesia, Opioids, and Other Drug Use During Pregnancy and Neonatal Abstinence Syndrome. Clin Perinatol 2019; 46:349-366. [PMID: 31010564 DOI: 10.1016/j.clp.2019.02.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
When opioid misuse rises in the United States, pregnant women and their neonates are affected. This article summarizes the use of Food and Drug Administration-approved products, including methadone, buprenorphine, and the combination formulation of buprenorphine and naloxone to treat adult opioid use disorder during the perinatal period. All labels include pregnancy, neonatal, and lactation information and note the accepted use of these medications during the perinatal period if the benefits outweigh the risks. A summary of the neonatal abstinence syndrome definition, its assessment tools, treatment approaches, and future genetic directions are provided.
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Affiliation(s)
- Hendrée E Jones
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, UNC Horizons, 410 North Greensboro Street, Chapel Hill, NC, USA; Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Department of Obstetrics and Gynecology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
| | - Walter K Kraft
- Clinical Research Unit, Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, 1170 Main Building, 132 South 10th Street, Philadelphia, PA 19107-5244, USA
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Neonatal Abstinence Syndrome: An Integrative Review of Neonatal Acupuncture to Inform a Protocol for Adjunctive Treatment. Adv Neonatal Care 2019; 19:165-178. [PMID: 31140978 DOI: 10.1097/anc.0000000000000630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND The current opioid epidemic in the United States has given rise to a growing incidence of neonatal abstinence syndrome (NAS). Treatments for this condition optimize nonpharmacologic therapies in an effort to improve withdrawal symptoms and reduce or eliminate the need for opioid medications, thereby reducing hospital length of stay and improving healthy neonatal outcomes. PURPOSE The purpose of this review was to evaluate the current evidence for neonatal acupuncture treatments and identify essential characteristics that must be included in a treatment protocol for NAS. METHODS/SEARCH STRATEGY An integrative review was conducted under the guidance of the Whittemore and Knafl methodology and near-term infant conceptual framework. An evaluation of the quality and levels of evidence was also included. FINDINGS/RESULTS A total of 10 studies were identified in this review. Four of these studies were randomized controlled trials, and utilized acupuncture in the neonatal population to evaluate impact on pain, NAS, and weight gain. IMPLICATIONS FOR PRACTICE This review provided the essential elements for the development of a complementary acupuncture treatment protocol for the management of NAS. IMPLICATIONS FOR RESEARCH Future research should include the identified essential characteristics in high-quality, blinded, randomized controlled trials to assess the treatment effect of acupuncture on neonates experiencing withdrawal symptoms.
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McCarty DB, Peat JR, O'Donnell S, Graham E, Malcolm WF. "Choose Physical Therapy" for Neonatal Abstinence Syndrome: Clinical Management for Infants Affected by the Opioid Crisis. Phys Ther 2019; 99:771-785. [PMID: 31155664 DOI: 10.1093/ptj/pzz039] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 02/13/2019] [Indexed: 11/14/2022]
Abstract
In response to the opioid crisis, the American Physical Therapy Association has strongly advocated for physical therapy as a safe alternative to pharmacological pain management through the "#ChoosePT" campaign and the dedication of a PTJ special issue to the nonpharmacological management of pain. Physical therapists not only play an important role in the rehabilitation of the nearly 2 million adolescents and adults addicted to prescription opioids but also provide care to infants born to mothers with various drug addictions. This Perspective article explores the incidence, pathophysiology, and risk factors for neonatal abstinence syndrome and describes the clinical presentations of withdrawal and neurotoxicity in infants. Discipline-specific recommendations for the physical therapist examination and plan of care, including pharmacological management considerations, are outlined. Nonpharmacological management, including supportive care, feeding, parent education, social aspects of care, and follow-up services, are discussed from a physical therapy perspective. Finally, this article reviews developmental outcomes in infants with neonatal abstinence syndrome and reflects on challenges and future directions of research in this area.
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Affiliation(s)
- Dana B McCarty
- Division of Physical Therapy, The University of North Carolina at Chapel Hill, 3044 Bondurant Hall, CB#7135, Chapel Hill, NC 27599 (USA)
| | - Jennifer R Peat
- Department of Physical Therapy, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Shannon O'Donnell
- Department of Physical and Occupational Therapy, Duke University Medical Center, Durham, North Carolina
| | - Elisabeth Graham
- Department of Physical and Occupational Therapy, Duke University Medical Center
| | - William F Malcolm
- Department of Pediatrics/Neonatology, Duke University Medical Center
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Abstract
Tens of thousands of infants are impacted yearly by prenatal opioid exposure. The term neonatal opioid withdrawal syndrome (NOWS) is now replacing the more familiar term neonatal abstinence syndrome (NAS). Ongoing debate continues related to standard regimens for treatment of this oftentimes perplexing condition. Historically, treatment has focused on pharmacologic interventions. However, there is limited research that points to nonpharmacologic methods of treatment as viable options, whether alone or in addition to pharmacologic interventions. This article, utilizing a review of pertinent literature, outlines the physical aspects of NOWS, including its pathophysiology and the resulting physical clinical signs. In addition, we present an overview of how age-appropriate, nonpharmacologic interventions, centered on developmental care, may be a valuable approach to organize and prioritize routine care for these infants, their families, and the health care team facing the challenges of NOWS. Finally, the need for further research to better define evidence-based standards of care for these infants and their families is discussed.
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Asadi A, Changizi-Ashtiyani S. Swaddling in Persian medicine. J Matern Fetal Neonatal Med 2018; 33:1958-1959. [PMID: 30269621 DOI: 10.1080/14767058.2018.1530756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Amin Asadi
- Department of History of Medical Sciences, Arak University of Medical Sciences, Arak, Iran
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Management of Neonatal Abstinence Syndrome: The Importance of a Multifaceted Program Spanning Inpatient and Outpatient Care. Jt Comm J Qual Patient Saf 2018; 44:309-311. [DOI: 10.1016/j.jcjq.2018.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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