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Economic Evaluation of Interventions for Treatment of Neonatal Opioid Withdrawal Syndrome: A Review. CHILDREN-BASEL 2021; 8:children8070534. [PMID: 34201863 PMCID: PMC8306925 DOI: 10.3390/children8070534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 06/18/2021] [Accepted: 06/19/2021] [Indexed: 11/17/2022]
Abstract
This study assessed the economic evidence on the pharmacological and non-pharmacological management of infants with neonatal opioid withdrawal syndrome (NOWS). Six databases were searched up to October 2020 for peer-reviewed studies. After titles and abstracts were screened, 79 studies remained for full-text review, and finally, 8 studies were eligible for inclusion in the review. The methodological quality of included studies was assessed using the Drummond checklist. The review showed significant limitations in these studies, with one study being rated as good and the remaining seven studies as of poor quality. There are methodological issues that require addressing, including a lack of detail on cost categories, a robust investigation of uncertainty, and extending the time horizon to consider longer-term outcomes beyond the initial birth hospitalization. Despite these limitations, existing evidence suggests non-pharmacological strategies such as rooming-in were associated with a shorter hospital stay and a decreased need for pharmacological treatment, thereby lowering hospitalization costs. The review highlights the paucity of high-quality studies assessing the cost-effectiveness of intervention strategies for NOWS. There is also a lack of evidence on long-term outcomes associated with NOWS and the treatment of NOWS. The inclusion of economic analyses in future studies will provide evidence to inform policymakers on resource allocation decisions for this patient population.
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Samiee-Zafarghandy S, van Donge T, Allegaert K, van den Anker J. Pharmacometric Evaluation of Umbilical Cord Blood Concentration-Based Early Initiation of Treatment in Methadone-Exposed Preterm Neonates. CHILDREN (BASEL, SWITZERLAND) 2021; 8:174. [PMID: 33668712 PMCID: PMC7996295 DOI: 10.3390/children8030174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/15/2021] [Accepted: 02/19/2021] [Indexed: 11/17/2022]
Abstract
In methadone-exposed preterm neonates, early identification of those at risk of severe neonatal abstinence syndrome (NAS) and use of a methadone dosing regimen that can provide effective and safe drug exposure are two important aspects of optimal care. To this end, we reviewed 17 methadone dosing recommendations in the international guidelines and literature and explored their variability in key dosing strategies. We selected three of the reviewed dosing regimens for their pharmacokinetics (PK) characteristics and their exposure-response relationship in three gestational age groups of preterm neonates (28, 32 and 36 gestational age weeks) at risk for development of severe NAS (defined as an umbilical cord methadone concentration of ≤60 ng/mL, following fetal exposure). We applied early (12 h after birth) vs. typical (36 h after birth) initiation of treatment. We observed that use of universally recommended dosing regimens in preterm neonates can result in under- or over-exposure. Use of a PK-guided dosing regimen resulted in effective target exposures within 24 h after birth with early initiation of treatment (12 h after birth). Future prospective studies should explore the incorporation of umbilical cord methadone concentrations for early identification of preterm neonates at risk of developing severe NAS and investigate the use of a PK-guided methadone dosing regimen, so that treatment failure, prolonged length of stay and opioid over-exposure can be avoided.
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Affiliation(s)
- Samira Samiee-Zafarghandy
- Division of Neonatology, Department of Paediatrics, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Tamara van Donge
- Division of Pediatric Pharmacology and Pharmacometrics, University Children’s Hospital Basel (UKBB), University of Basel, 4056 Basel, Switzerland; (T.v.D.); (J.v.d.A.)
| | - Karel Allegaert
- Department of Clinical Pharmacy, Erasmus MC, Postbus 2040, 3000 CA Rotterdam, The Netherlands;
- Department of Development and Regeneration, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - John van den Anker
- Division of Pediatric Pharmacology and Pharmacometrics, University Children’s Hospital Basel (UKBB), University of Basel, 4056 Basel, Switzerland; (T.v.D.); (J.v.d.A.)
- Division of Clinical Pharmacology, Children’s National Health Hospital, Washington, DC 20010, USA
- Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children’s Hospital, 3015 GD Rotterdam, The Netherlands
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Mian P, Tibboel D, Wildschut ED, van den Anker JN, Allegaert K. Morphine treatment for neonatal abstinence syndrome: huge dosing variability underscores the need for a better clinical study design. Minerva Pediatr 2019; 71:263-286. [DOI: 10.23736/s0026-4946.17.04928-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Neonatal abstinence syndrome refers to the signs and symptoms attributed to the cessation of prenatal exposure (via placental transfer) to various substances. This Primer focuses on neonatal abstinence syndrome caused by opioid use during pregnancy - neonatal opioid withdrawal syndrome (NOWS). As the global prevalence of opioid use has alarmingly increased, so has the incidence of NOWS. NOWS can manifest with varying severity or not at all, for unknown reasons, but is likely to be associated with multiple factors, both maternal (for example, smoking and additional substance exposures) and neonatal (gestational age, sex and genetics). Care for the infant with NOWS begins with addressing the issues experienced by pregnant women with opioid use disorder. Co-occurring mental illness, economic hardship, intimate partner violence, infectious diseases and limited access to care are common in these women and can result in poor maternal and neonatal outcomes. Although there is no consensus regarding optimal NOWS management, non-pharmacological interventions (such as breastfeeding and rooming-in of the mother and the baby) have become a priority, as they can ameliorate symptoms without the need for further opioid exposure. Untreated NOWS can be associated with morbidity in early infancy, and the long-term consequences of fetal opioid exposure are only beginning to be understood.
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Affiliation(s)
- Mara G Coyle
- Department of Pediatrics, The Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | - Susan B Brogly
- Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | - Mahmoud S Ahmed
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX, USA
| | - Stephen W Patrick
- Vanderbilt Center for Child Health Policy, Department of Pediatrics and Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hendrée E Jones
- Department of Obstetrics and Gynecology, University of North Carolina, Carrboro, NC, USA
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Abstract
Aim The purpose of this systematic review was to assess the literature regarding the effectiveness and safety of outpatient pharmacologic weaning for infants with neonatal abstinence syndrome (NAS). Background NAS is a multi-system disorder observed in infants experiencing withdrawal from opioid exposure in utero. Infants requiring pharmacologic treatment to manage withdrawal, traditionally receive treatment as a hospital inpatient resulting in lengthy hospitalization periods. However, there is evidence to suggest that some healthcare institutions are continuing outpatient pharmacologic weaning for select infants in a home environment. As there is no standard of care to guide outpatient weaning, assessment of the safety and effectiveness of this approach is warranted. Method A systematic review of outpatient weaning for infants with NAS was conducted using the electronic databases PubMed, Nursing and Allied Health, CINAHL, Evidence-Based Medicine, Web of Science, Medline, and PsychINFO. Studies were eligible for inclusion in the review if they fulfilled the following criteria: (1) reported original data on outcomes related to the effectiveness or safety of outpatient weaning for infants with NAS, (2) infants were discharged from hospital primarily receiving opioid pharmacologic treatment for NAS, (3) the method included quantitative designs that included an inpatient comparison group, and (4) articles were published in English in a peer-reviewed journal. Findings The search identified 154 studies, of which 18 provided information related to NAS and outpatient weaning. After reviewing the remaining full-text studies, six studies met all inclusion and exclusion criteria. All studies identified that outpatient weaning for select infants was associated with shorter hospitalization compared with infants weaned in-hospital only and may be potentially effective in reducing associated healthcare costs. However, duration of pharmacologic treatment was longer in the outpatient weaning groups in the majority of the studies. Furthermore, adverse events were rare and compliance to follow-up treatment was high among those who received outpatient weaning.
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Barbeau DY, Weiss MD. Sleep Disturbances in Newborns. CHILDREN (BASEL, SWITZERLAND) 2017; 4:E90. [PMID: 29053622 PMCID: PMC5664020 DOI: 10.3390/children4100090] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 10/10/2017] [Accepted: 10/17/2017] [Indexed: 12/27/2022]
Abstract
The purpose of this review is to serve as an introduction to understanding sleep in the fetus, the preterm neonate and the term neonate. Sleep appears to have numerous important roles, particularly in the consolidation of new information. The sleep cycle changes over time, neonates spend the most time in active sleep and have a progressive shortening of active sleep and lengthening of quiet sleep. Additionally, the sleep cycle is disrupted by many things including disease state and environment, and the amplitude integrated EEG can be a useful tool in evaluating sleep, and sleep disturbances, in neonates. Finally, there are protective factors for infant sleep that are still being studied.
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Affiliation(s)
| | - Michael D Weiss
- Department of Pediatrics, University of Florida, Gainesville, FL 32610, USA.
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A management strategy that reduces NICU admissions and decreases charges from the front line of the neonatal abstinence syndrome epidemic. J Perinatol 2017; 37:1108-1111. [PMID: 28682317 PMCID: PMC5633652 DOI: 10.1038/jp.2017.101] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 04/26/2017] [Accepted: 05/22/2017] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The purpose of this study was to test a specialized needs-based management model for a high volume of babies born with neonatal abstinence syndrome (NAS) while controlling costs and reducing neonatal intensive care unit (NICU) bed usage. STUDY DESIGN Data were analyzed from inborn neonates >35 weeks' gestational age with the diagnosis of NAS (ICD9-CM 779.5), requiring pharmacologic treatment and discharged from 2010 through 2015. Significance was determined using Kruskal-Wallis and Mann-Whitney as well as χ2 for trend. RESULTS NAS requiring medication treatment increased from 34.1 per 1000 live births in 2010 to 94.3 per 1000 live births in 2015 (P<0.0001 for trend). Hospital charges were significantly different in the three described locations (P<0.0001). Median per patient hospital charges for medically treated NAS were $90 601 (interquartile range (IQR) $64 489 to $128 135) for NAS patients managed in the NICU, $68 750 (IQR $44 952 to $92 548) for those managed in an in-hospital dedicated unit and $17 688 (IQR $9933 to $20 033) for those cared for in an outpatient neonatal withdrawal center. NICU admission was avoided in 78% of the population once both alternative locations were fully implemented. CONCLUSIONS In this cohort of infants, a 219% increase in the number of infants treated for NAS overwhelmed the capacity of our traditional resources. There was a need to develop new treatment approaches dealing with the NAS crisis and a growing population of prenatally exposed babies. We found that the described model of care significantly reduced charges and stabilized admissions to our NICU despite the marked increase in cases. Without this system, our NICU would be in a critical state of gridlock and diversion; instead, we have efficient management of a large NAS population.
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Raffaeli G, Cavallaro G, Allegaert K, Wildschut ED, Fumagalli M, Agosti M, Tibboel D, Mosca F. Neonatal Abstinence Syndrome: Update on Diagnostic and Therapeutic Strategies. Pharmacotherapy 2017; 37:814-823. [DOI: 10.1002/phar.1954] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Genny Raffaeli
- NICU; Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico; Università degli Studi di Milano; Milan Italy
| | - Giacomo Cavallaro
- NICU; Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico; Università degli Studi di Milano; Milan Italy
| | - Karel Allegaert
- Department of Development and Regeneration; KU Leuven; Leuven Belgium
| | - Enno Diederik Wildschut
- Intensive Care and Department of Pediatric Surgery; Erasmus MC-Sophia Children's Hospital; Rotterdam The Netherlands
| | - Monica Fumagalli
- NICU; Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico; Università degli Studi di Milano; Milan Italy
| | | | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery; Erasmus MC-Sophia Children's Hospital; Rotterdam The Netherlands
| | - Fabio Mosca
- NICU; Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico; Università degli Studi di Milano; Milan Italy
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Wang X, Zhu Y, Dave CV, Alrwisan AA, Voils SA, Winterstein AG. Trends of Neonatal Abstinence Syndrome Epidemic and Maternal Risk Factors in Florida. Pharmacotherapy 2017; 37:806-813. [PMID: 28500694 DOI: 10.1002/phar.1947] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE This study aimed to examine secular trends of (i) maternal prescription opioid use in late pregnancy, (ii) neonatal abstinence syndrome (NAS) stratified by late maternal prescription opioid use, and (iii) maternal risk factors among NAS deliveries. METHODS Women with a live birth who were enrolled 90 days before and 30 days after delivery in Florida Medicaid Analytic Extract billing records linked to birth certificates from 2000 to 2010 were identified for the study. Changes in the annual prevalence of prescription opioid use during pregnancy were tested with use of the Cochran-Armitage trend test. Temporal trends of NAS deliveries were estimated with the use of Poisson regression and stratified by prescription opioid exposure in the last 90 days of pregnancy in the study period. To identify contributors to the increase in NAS cases, variations in prevalence of opioid dispensing, tobacco use, antidepressant use, and substance use disorder among NAS and non-NAS deliveries were examined. RESULTS There were 41,968 (9.4%) deliveries exposed to at least one opioid prescription in late pregnancy, and this rate remained stable from 2000 to 2010. Among prescription opioid-exposed deliveries, frequency of NAS increased from 1.6 to 25.2 per 1000 live births during the study period (p<0.05). Although the prevalence of maternal use of prescription opioid, tobacco, and antidepressants remained stable among NAS deliveries from 2000 to 2010, the prevalence of substance use disorder diagnoses increased substantially from 38.9% in 2000 to 67.9% in 2006 (p<0.05). CONCLUSIONS The prevalence of NAS increased dramatically whereas the prevalence of major risk factors, including maternal prescription opioid use, remained stable in Florida between 2000 and 2010. The increase in substance use disorder may be responsible for the sharp increase in NAS deliveries.
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Affiliation(s)
- Xi Wang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Yanmin Zhu
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Chintan V Dave
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Adel A Alrwisan
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida.,National Pharmacovigilance Center, Saudi Food and Drug Authority, Riyadh, Saudi Arabia
| | - Stacy A Voils
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida.,Department of Epidemiology, College of Public Health and Health Professions, University of Florida, Gainesville, Florida
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Chau KT, Nguyen J, Miladinovic B, Lilly CM, Ashmeade TL, Balakrishnan M. Outpatient Management of Neonatal Abstinence Syndrome: A Quality Improvement Project. Jt Comm J Qual Patient Saf 2016; 42:506-515. [PMID: 28266919 DOI: 10.1016/s1553-7250(16)42093-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND An increasing number of infants are diagnosed with neonatal abstinence syndrome (NAS). The study's primary objectives were to describe an academic medical center's level IV neonatal ICU's (NICU's) comprehensive outpatient NAS management effort, measure guideline compliance, and assess its safety. Secondary objectives were to describe the duration and cumulative methadone exposure, and to improve parent and provider knowledge of NAS. METHODS The study included 22 infants having a gestational age of 35-41 weeks, diagnosed with NAS, and discharged for outpatient methadone management. Discharges spanned 10 months and included 3 improvement periods. The outpatient program includes comprehensive discharge planning, a focused electronic health record (EHR) template, management guidelines, and parent and provider education. RESULTS Providers complied with using the outpatient management guideline and EHR template, and assessed weight, NAS symptoms, and methadone dose during appointments. Two infants required NAS-related hospital readmission in the study period. From improvement period 1 to period 3 there was no difference in total outpatient days on methadone (58, 53, 74 days, respectively) or cumulative methadone dose (2.7, 2.6, 3.1mg/kg, respectively). A downward trend pattern in cumulative methadone exposure was noted in improvement period 2. Pre- and postimplementation surveys revealed that after implementation, parents had better understanding of NAS before delivery (71% vs. 100%, p = 0.009), while providers had increased comfort with outpatient management (24% vs. 67%, p < 0.001) and educating parents (48% vs. 82%, p = 0.001). CONCLUSION This preliminary study suggests that outpatient NAS management can be safe when a comprehensive management program is implemented and can result in provider compliance with the program.
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Affiliation(s)
- Kim T Chau
- Formerly resident, Pediatrics, University of South Florida (USF), Tampa; Pediatrician, Matagorda Episcopal Health Outreach Program's Pediatric Clinic, Bay City, Texas
| | | | - Branko Miladinovic
- Assistant Professor, Comparative Effectiveness Research, USF; Assistant Professor, USF Morsani College of Medicine
| | - Carol M Lilly
- Associate Professor, USF Morsani College of Medicine and the College of Public Health; Division Chief, General Academic Pediatrics and Pediatrics
| | - Terri L Ashmeade
- Professor of Pediatrics, USF Morsani College of Medicine; Chief Quality Officer, USF Health
| | - Maya Balakrishnan
- Associate Professor, Pediatrics, USF Morsani College of Medicine; Medical Director of Quality, Florida Perinatal Quality Collaborative, USF Health, Tampa.
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Tolia VN, Patrick SW, Bennett MM, Murthy K, Sousa J, Smith PB, Clark RH, Spitzer AR. Increasing incidence of the neonatal abstinence syndrome in U.S. neonatal ICUs. N Engl J Med 2015; 372:2118-26. [PMID: 25913111 DOI: 10.1056/nejmsa1500439] [Citation(s) in RCA: 320] [Impact Index Per Article: 35.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The incidence of the neonatal abstinence syndrome, a drug-withdrawal syndrome that most commonly occurs after in utero exposure to opioids, is known to have increased during the past decade. However, recent trends in the incidence of the syndrome and changes in demographic characteristics and hospital treatment of these infants have not been well characterized. METHODS Using multiple cross-sectional analyses and a deidentified data set, we analyzed data from infants with the neonatal abstinence syndrome from 2004 through 2013 in 299 neonatal intensive care units (NICUs) across the United States. We evaluated trends in incidence and health care utilization and changes in infant and maternal clinical characteristics. RESULTS Among 674,845 infants admitted to NICUs, we identified 10,327 with the neonatal abstinence syndrome. From 2004 through 2013, the rate of NICU admissions for the neonatal abstinence syndrome increased from 7 cases per 1000 admissions to 27 cases per 1000 admissions; the median length of stay increased from 13 days to 19 days (P<0.001 for both trends). The total percentage of NICU days nationwide that were attributed to the neonatal abstinence syndrome increased from 0.6% to 4.0% (P<0.001 for trend), with eight centers reporting that more than 20% of all NICU days were attributed to the care of these infants in 2013. Infants increasingly received pharmacotherapy (74% in 2004-2005 vs. 87% in 2012-2013, P<0.001 for trend), with morphine the most commonly used drug (49% in 2004 vs. 72% in 2013, P<0.001 for trend). CONCLUSIONS From 2004 through 2013, the neonatal abstinence syndrome was responsible for a substantial and growing portion of resources dedicated to critically ill neonates in NICUs nationwide.
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Affiliation(s)
- Veeral N Tolia
- From the Division of Neonatology, Department of Pediatrics, Baylor University Medical Center, Pediatrix Medical Group (V.N.T.), and the Office of the Chief Quality Officer, Baylor Scott and White Health (M.M.B.) - all in Dallas; the Mildred Stahlman Division of Neonatology, Department of Pediatrics, and the Vanderbilt Center for Health Services Research and Department of Health Policy, Vanderbilt University School of Medicine, Nashville (S.W.P.); the Division of Neonatology, Department of Pediatrics, Feinberg School of Medicine, Northwestern University, and Ann and Robert H. Lurie Children's Hospital of Chicago - both in Chicago (K.M.); the Department of Biomedical Sciences, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton (J.S.), and the Center for Research, Education, and Quality, Mednax, Sunrise (R.H.C., A.R.S.) - both in Florida; the Department of Pediatrics, Duke University School of Medicine, Durham, NC (P.B.S.); and Pediatrix Medical Group, Greenville Memorial Hospital, Greenville, SC (R.H.C.)
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Nayeri F, Sheikh M, Kalani M, Niknafs P, Shariat M, Dalili H, Dehpour AR. Phenobarbital versus morphine in the management of neonatal abstinence syndrome, a randomized control trial. BMC Pediatr 2015; 15:57. [PMID: 25976238 PMCID: PMC4438473 DOI: 10.1186/s12887-015-0377-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 05/08/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUNDS Evaluating the efficacy of the loading and tapering dose of Phenobarbital versus oral Morphine in the management of NAS. METHODS This randomized, open-label, controlled trial was conducted on 60 neonates born to illicit drugs dependent mothers at Vali-Asr and Akbar-Abadi hospitals, Tehran, Iran, who exhibited NAS requiring medical therapy. The neonates were randomized to receive either: Oral Morphine Sulfate or a loading dose of Phenobarbital followed by a tapering dose. The duration of treatment required for NAS resolution, the total hospital stay and the requirement for additional second line treatment were compared between the treatment groups. RESULTS The Mean ± Standard Deviation for the duration of treatment required for the resolution of NAS was 8.5 ± 5 days in the Morphine group and 8.5 ± 4 days in the Phenobarbital group (P = 0.9). The duration of total hospital stay was 12.6 ± 5.6 days in the Morphine group and 12.5 ± 5.3 days in the Phenobarbital group (P = 0.7). 3.3 % in the Morphine group versus 6.6 % in the Phenobarbital group required adjunctive treatment (P = 0.5). CONCLUSIONS There were no significant differences in the duration of treatment, duration of hospital stay, and the requirement for adjunctive treatment, between the neonates with NAS who received Morphine Sulfate and neonates who received a loading and tapering dose of Phenobarbital. TRIAL REGISTRATION This study is registered at the Iranian Registry of Clinical Trials ( www.irct.ir ) which is a Primary Registry in the WHO Registry Network. (Registration Number = IRCT201406239568N8 ).
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Affiliation(s)
- Fatemeh Nayeri
- Maternal, Fetal and Neonatal Research Center, Tehran University of Medical Sciences, Tehran, Iran.
- Breastfeeding Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mahdi Sheikh
- Maternal, Fetal and Neonatal Research Center, Tehran University of Medical Sciences, Tehran, Iran.
- Breastfeeding Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Majid Kalani
- Department of Neonatology, Akbar-Abadi Hospital, Iran University of Medical Sciences, Tehran, Iran.
| | - Pedram Niknafs
- Pediatrics Department, Kerman University of Medical Sciences, Kerman, Iran.
| | - Mamak Shariat
- Maternal, Fetal and Neonatal Research Center, Tehran University of Medical Sciences, Tehran, Iran.
- Breastfeeding Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Hosein Dalili
- Breastfeeding Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Ahmad-Reza Dehpour
- Department of Pharmacology, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
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Abstract
Neonatal abstinence syndrome (NAS) is reaching epidemic proportions related to perinatal use of opioids. There are many approaches to assess and manage NAS, including one we have outlined. A standardized approach is likely to reduce length of stay and variability in practice. Circumcision is a frequent, painful procedure performed in the neonatal period. The rationale for providing analgesia is presented as well as a review of methods. Pharmacogenomics and pharmacogenetics have expanded our understanding of diseases and their drug therapy. Some applications of pharmacogenomics to the neonatal period are presented, along with pediatric challenges of developmental expression of drug-metabolizing enzymes.
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Lee J, Hulman S, Musci M, Stang E. Neonatal Abstinence Syndrome: Influence of a Combined Inpatient/Outpatient Methadone Treatment Regimen on the Average Length of Stay of a Medicaid NICU Population. Popul Health Manag 2015; 18:392-7. [PMID: 25803316 PMCID: PMC4675180 DOI: 10.1089/pop.2014.0134] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Prescription opioid and heroin abuse have been increasing steadily year after year, and continue to be a serious national problem. A sequela of the increase in opioid abuse has been an increase in the number of infants born with opioid dependence. These infants often require costly, prolonged stays in the neonatal intensive care unit (NICU) for drug withdrawal treatment. The authors studied a population of infants from a large Medicaid health plan who were born with neonatal abstinence syndrome (NAS) secondary to in utero opioid exposure to assess the average length of stay in the NICU, and to determine the variables that may account for differences in interinstitutional lengths of stay. The overall average length of stay for NAS was 21.1 days for the 139 infants included in the study. Analysis of the medication used for treatment revealed that infants who were treated with a combined inpatient/outpatient regimen with methadone had an average length of stay of 11.4 days versus 25.1 days for infants who were treated entirely as inpatients (P<0.001), a 55% reduction in average length of stay. In 2009 there were an estimated 13,600 cases of NAS in the United States at a cost of $53,000 per case. A 55% reduction in length of stay corresponds to $396 million in annual savings for the treatment of NAS. Development of successful combined inpatient/outpatient management programs for NAS warrants further consideration. (Population Health Management 2015;18:392–397)
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Affiliation(s)
- Jerry Lee
- 1 ProgenyHealth , Plymouth Meeting, Pennsylvania
| | - Sonia Hulman
- 1 ProgenyHealth , Plymouth Meeting, Pennsylvania
| | | | - Ellen Stang
- 1 ProgenyHealth , Plymouth Meeting, Pennsylvania
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Abstract
Neonatal abstinence syndrome (NAS) is a result of the sudden discontinuation of fetal exposure to substances that were used or abused by the mother during pregnancy. Withdrawal from licit or illicit substances is becoming more common among neonates in both developed and developing countries. NAS continues to be an important clinical entity throughout much of the world. NAS leads to a constellation of signs and symptoms involving multiple systems. The pathophysiology of NAS is not completely understood. Urine or meconium confirmation may assist the diagnosis and management of NAS. The Finnegan scoring system is commonly used to assess the severity of NAS; scoring can be helpful for initiating, monitoring, and terminating treatment in neonates. Nonpharmacological care is the initial treatment option, and pharmacological treatment is required if an improvement is not observed after nonpharmacological measures or if the infant develops severe withdrawal. Morphine is the most commonly used drug in the treatment of NAS secondary to opioids. An algorithmic approach to the management of infants with NAS is suggested. Breastfeeding is not contraindicated in NAS, unless the mother is taking street drugs, is involved in polydrug abuse, or is infected with HIV. Future studies are required to assess the long-term effects of NAS on children after prenatal exposure.
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Affiliation(s)
- Prabhakar Kocherlakota
- Division of Neonatology, Department of Pediatrics, Maria Fareri Children's Hospital at New York Medical College, Valhalla, New York
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Abstract
PURPOSE OF REVIEW This review will summarize the symptoms, evaluation, and treatment of neonatal and iatrogenic withdrawal syndromes. RECENT FINDINGS Buprenorphine is emerging as the drug of choice for maintaining opioid-dependent women during pregnancy, because of its association with less severe withdrawal symptoms. Recent findings suggest it may be the drug of choice for treating the opioid-exposed neonate as well. SUMMARY Healthcare workers should be cognizant of the risk factors for neonatal abstinence syndrome (NAS), as well as its symptoms, so that nonpharmalogic and pharmacologic therapies can be initiated. With increased emphasis on pain control in children, it is likely that iatrogenic withdrawal will continue to be a concern, and healthcare workers should understand the similarities and differences between this and NAS.
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