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Sealschott S, Pickler R, Fortney C, Bailey M, Loman B. Gut Microbiota and Symptom Expression and Severity in Neonatal Abstinence Syndrome. Biol Res Nurs 2024; 26:460-468. [PMID: 38528812 DOI: 10.1177/10998004241242102] [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: 03/27/2024]
Abstract
Problem: Neonatal abstinence syndrome (NAS) affecting neonates with fetal exposure to opioids, is defined by expression and severity of symptoms. The pathophysiology behind symptoms variability is lacking. The study aims were to examine (a) differences in gut microbiota of neonates with and without NAS, (b) the relationships between gut microbiota and symptom expression and NAS severity, and (c) the changes in the neonate gut microbiota diversity during the course of NAS treatment. Methods: A cross-sectional observational design was used to examine differences in microbiota and a longitudinal, repeated measures approach was used to determine relationships between gut microbiota and NAS symptoms. Symptom data were collected using the Finnegan Neonatal Abstinence Scoring Tool and the Neonatal Pain Agitation and Sedation Scale. Stool samples were collected for microbiome analyses with 16S rRNA microbiome sequencing. Results: Differences in alpha and beta diversity between neonates with and without NAS were seen. Relative abundance results revealed 18 taxa were different in neonates with NAS compared to neonates without NAS. No differences were found in alpha or beta diversity in neonates with NAS between enrollment and hospital discharge. There was increased abundance of Escherichia-Shigella and Bacteriodes genera related to higher symptom scores. Discussion: Differences in alpha and beta diversity between neonates with and without NAS may be due to differences in birth mode and type of feeding. The findings of specific increased bacteria related to increased symptoms in the neonates with NAS may also be influenced by birth mode and type of feeding.
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Affiliation(s)
| | - Rita Pickler
- The Ohio State University College of Nursing, Columbus, OH, USA
| | | | - Michael Bailey
- The Ohio State University College of Nursing, Columbus, OH, USA
- Center for Microbial Pathogenesis, Columbus, The Research Institute at Nationwide Children's Hospital, OH, USA
| | - Brett Loman
- University of Illinois Urbana-Champaign, Urbana, IL, USA
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Hite MK, Chroust AJ, Proctor-Williams K, Lowe JL. Newborn Hearing Screening Results for Infants With Prenatal Opioid Exposure in Southern Appalachia. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2024; 67:1268-1280. [PMID: 38517271 DOI: 10.1044/2024_jslhr-23-00492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
PURPOSE Infants prenatally exposed to opioids exhibit withdrawal symptomology that introduce physiological noise and can impact newborn hearing screening results. This study compared the referral rate and physiological noise interpreted by number of trials rejected due to artifact on initial newborn hearing screenings of infants with prenatal opioid exposure (POE) and infants with no opioid exposure (NOE). Furthermore, within the POE group, it examined the relationship of referral rates with severity of withdrawal symptomology, and with maternal and infant risk factors. METHOD This study used a retrospective cohort design of electronic medical records from six delivery hospitals in South-Central Appalachia. Newborn hearing screenings were conducted using automated auditory brainstem response (ABR) for 334 infants with POE and 226 infants with NOE. Severity of withdrawal symptomology was measured using the Modified Finnegan Neonatal Abstinence Scoring Tool, which includes observation of behaviors that introduce physiological noise. RESULTS There was no significant difference in newborn hearing screening referral rate between infants with POE and infants with NOE. Referral rate was not affected by maternal or infant risk factors. Infants with POE had statistically significant higher artifact (defined as rejected ABR sweeps) than infants with NOE. There was a strong positive correlation between Finnegan scores and artifact but not referral rates. Sensitivity and specificity analysis indicated artifact decreased substantially after Day 4 of life. CONCLUSIONS Referral rates of infants with POE were similar to those of infants with NOE. Nevertheless, the withdrawal symptomology of infants with POE introduces physiological noise reflected as artifact on ABR, which can affect efficiency of newborn hearing screenings.
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Affiliation(s)
- Marcy K Hite
- Department of Audiology and Speech Language Pathology, East Tennessee State University, Johnson City
| | - Alyson J Chroust
- Department of Psychology, East Tennessee State University, Johnson City
| | - Kerry Proctor-Williams
- Department of Audiology and Speech Language Pathology, East Tennessee State University, Johnson City
| | - Jennifer L Lowe
- Department of Audiology and Speech Language Pathology, East Tennessee State University, Johnson City
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James L, Venable T, Caro A, Moran JH, Nesmith C, Gannon MA, Cornett LE. Development of a clinical and translational research curriculum for undergraduate students. J Clin Transl Sci 2023; 7:e118. [PMID: 37313383 PMCID: PMC10260337 DOI: 10.1017/cts.2023.532] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 03/03/2023] [Accepted: 04/11/2023] [Indexed: 06/15/2023] Open
Abstract
Introduction Research participation during undergraduate years has a powerful influence on career selection and attitudes toward scientific research. Most undergraduate research programs in academic health centers are oriented toward basic research or address a particular disease focus or research discipline. Undergraduate research programs that expose students to clinical and translational research may alter student perceptions about research and influence career selection. Methods We developed an undergraduate summer research curriculum, anchored upon a clinical and translational research study developed to address a common unmet needs in neonatal nurseries (e.g., assessment of neonatal opioid withdrawal syndrome). Program topics reflected the cross-disciplinary expertise that contributed to the development of this "bedside to bench" study, including opioid addiction, vulnerable populations, research ethics, statistics, data collection and management, assay development, analytical laboratory analysis, and pharmacokinetics. The curriculum was delivered through three offerings over 12 months, using Zoom video-conferencing due to restrictions imposed by the COVID-19 pandemic. Results Nine students participated in the program. Two-thirds reported the course enhanced their understanding of clinical and translational research. Over three-quarters reported the curriculum topics were very good or excellent. In open-ended questions, students reported that the cross-disciplinary nature of the curriculum was the strongest aspect of the program. Conclusion The curriculum could be readily adapted by other Clinical and Translational Science Award programs seeking to provide clinical and translational research-oriented programs to undergraduate students. Application of cross-disciplinary research approaches to a specific clinical and translational research question provides students with relevant examples of translational research and translational science.
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Affiliation(s)
- Laura James
- The Departments of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Tara Venable
- The Departments of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Andres Caro
- Department of Chemistry, Hendrix College, Conway, AR, USA
| | - Jeffrey H. Moran
- Department of Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Claire Nesmith
- The Departments of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Matthew A. Gannon
- Community Health and Research, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Lawrence E. Cornett
- Department of Physiology and Cell Biology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Abstract
Neonatal abstinence syndrome (NAS) is a significant public health problem in the United States. The most commonly used tool to assess and treat infants with NAS is the Finnegan Neonatal Abstinence Scoring System (FNASS). The more recently developed Eat, Sleep, Console (ESC) method simplifies assessment of NAS. Current research suggests promising outcomes with the ESC method in areas such as length of hospital stay (LOS) and amount of medication needed to treat NAS. A literature review was conducted to answer the following question: In newborn infants with NAS born at 36 weeks of gestation or older, does the ESC method reduce the use of medication and LOS when compared with the FNASS? All of the studies reporting on LOS and medication usage rates reported a decrease in both when moving to the ESC method from FNASS.
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Young LW, Ounpraseuth S, Merhar SL, Simon AE, Das A, Greenberg RG, Higgins RD, Lee J, Poindexter BB, Smith PB, Walsh M, Snowden J, Devlin LA. Eating, Sleeping, Consoling for Neonatal Opioid Withdrawal (ESC-NOW): a Function-Based Assessment and Management Approach study protocol for a multi-center, stepped-wedge randomized controlled trial. Trials 2022; 23:638. [PMID: 35945598 PMCID: PMC9361241 DOI: 10.1186/s13063-022-06445-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 06/02/2022] [Indexed: 12/05/2022] Open
Affiliation(s)
- Leslie W. Young
- Department of Pediatrics, Larner College of Medicine at the University of Vermont, 111 Colchester Ave Smith 5, Burlington, VT 05401 USA
| | - Songthip Ounpraseuth
- University of Arkansas for Medical Sciences, 4301 W. Markham St., Little Rock, AR 72205 USA
| | - Stephanie L. Merhar
- Department of Pediatrics, University of Cincinnati, 3333 Burnet Ave ML7009, Cincinnati, OH 45229 USA
| | - Alan E. Simon
- Environmental Influences on Child Health Outcomes (ECHO) Program, Office of the Director, the National Institutes of Health, Three White Flint North 11601 Landsdown Street, Office 3D16, North Bethesda, MD 20852 USA
| | - Abhik Das
- RTI International, 3040 East Cornwallis Road, Research Triangle Park, NC 27709-2194 USA
| | - Rachel G. Greenberg
- Duke University School of Medicine Duke Clinical Research Institute, 300 W. Morgan St, Durham, NC 27701 USA
| | - Rosemary D. Higgins
- College of Health and Human Services George Mason University, 4400 University Drive 2G7 Peterson Family Health Science Hall Room 5415 Fairfax, Virginia, 22030 USA
| | - Jeannette Lee
- University of Arkansas for Medical Sciences, 4301 West Markham, #781 COPH Room 3234, Little Rock, Arkansas 72205-7199 USA
| | - Brenda B. Poindexter
- Emory University School of Medicine, 2015 Uppergate Dr. NE, Suite 304, Atlanta, GA 30322 USA
| | - P. Brian Smith
- Duke University School of Medicine Duke Clinical Research Institute, 300 W. Morgan St, Durham, NC 27701 USA
| | - Michele Walsh
- Pregnancy and Perinatology Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6710 Rockledge Dr. Wing B, Rm2321-D, Bethesda, MD 20892-7002 USA
| | - Jessica Snowden
- Arkansas Children’s Research Institute, University of Arkansas for Medical Sciences, 13 Children’s Way, ACRI Slot 512-35, Little Rock, AR 72202 USA
| | - Lori A. Devlin
- Department of Pediatrics, University of Louisville School of Medicine, 571 South Floyd Street Suite 342, Louisville, KY 40202 USA
| | - for the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network and the NIH Environmental influences on Child Health Outcomes (ECHO) Program Institutional Development Awards States Pediatric Clinical Trials Network
- Department of Pediatrics, Larner College of Medicine at the University of Vermont, 111 Colchester Ave Smith 5, Burlington, VT 05401 USA
- University of Arkansas for Medical Sciences, 4301 W. Markham St., Little Rock, AR 72205 USA
- Department of Pediatrics, University of Cincinnati, 3333 Burnet Ave ML7009, Cincinnati, OH 45229 USA
- Environmental Influences on Child Health Outcomes (ECHO) Program, Office of the Director, the National Institutes of Health, Three White Flint North 11601 Landsdown Street, Office 3D16, North Bethesda, MD 20852 USA
- RTI International, 3040 East Cornwallis Road, Research Triangle Park, NC 27709-2194 USA
- Duke University School of Medicine Duke Clinical Research Institute, 300 W. Morgan St, Durham, NC 27701 USA
- College of Health and Human Services George Mason University, 4400 University Drive 2G7 Peterson Family Health Science Hall Room 5415 Fairfax, Virginia, 22030 USA
- University of Arkansas for Medical Sciences, 4301 West Markham, #781 COPH Room 3234, Little Rock, Arkansas 72205-7199 USA
- Emory University School of Medicine, 2015 Uppergate Dr. NE, Suite 304, Atlanta, GA 30322 USA
- Pregnancy and Perinatology Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6710 Rockledge Dr. Wing B, Rm2321-D, Bethesda, MD 20892-7002 USA
- Arkansas Children’s Research Institute, University of Arkansas for Medical Sciences, 13 Children’s Way, ACRI Slot 512-35, Little Rock, AR 72202 USA
- Department of Pediatrics, University of Louisville School of Medicine, 571 South Floyd Street Suite 342, Louisville, KY 40202 USA
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Isaacs KR, Atreyapurapu S, Alyusuf AH, Ledgerwood DM, Finnegan LP, Chang KHK, Ma TX, Washio Y. Neonatal Outcomes after Combined Opioid and Nicotine Exposure in Utero: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:10215. [PMID: 34639512 PMCID: PMC8508043 DOI: 10.3390/ijerph181910215] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/03/2021] [Accepted: 09/21/2021] [Indexed: 12/02/2022]
Abstract
BACKGROUND The majority of women who are pregnant with opioid use disorder (OUD) also smoke tobacco but are rarely offered tobacco cessation counseling. While the effects of exposure to opioids and nicotine in utero are well-understood separately, understanding the impact of the combined exposure to these substances on neonatal outcomes is lacking. METHODS A scoping review was conducted using PubMed and Scopus databases for studies addressing the combined exposure to opioids and nicotine during pregnancy published between 1 January 1980 and 9 July 2019. A total of 29 papers met the eligibility criteria for inclusion, with nine being identified as clinical trials (three from the MOTHER study) and two as secondary data analysis of clinical trial data. RESULTS Neonatal outcomes for infants who had a combined exposure to opioids and nicotine in utero indicated a reduction in birth weight and birth length. Findings in infants exposed to both nicotine and opioids were mixed with regard to the duration of neonatal abstinence syndrome (NAS), the likelihood of treatment for NAS, doses of medicine used to treat NAS, and NAS scores when compared with infants who had opioid exposure without nicotine. CONCLUSIONS The combined exposure to nicotine and opioids during pregnancy may lead to a reduction in neonatal birth weight and birth length and more severe NAS signs, compared with opioid use alone, but more research is necessary to identify the minimum dosage and length of nicotine exposure to accurately predict these outcomes.
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Affiliation(s)
- Krystyna R. Isaacs
- Benten Technologies, 9408 Grant Ave Suite 206, Manassas, VA 20110, USA; (K.R.I.); (S.A.); (A.H.A.); (K.H.K.C.); (T.X.M.)
| | - Sravanthi Atreyapurapu
- Benten Technologies, 9408 Grant Ave Suite 206, Manassas, VA 20110, USA; (K.R.I.); (S.A.); (A.H.A.); (K.H.K.C.); (T.X.M.)
| | - Amal H. Alyusuf
- Benten Technologies, 9408 Grant Ave Suite 206, Manassas, VA 20110, USA; (K.R.I.); (S.A.); (A.H.A.); (K.H.K.C.); (T.X.M.)
| | - David M. Ledgerwood
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, 3901 Chrysler Service Drive, Detroit, MI 48201, USA;
| | - Loretta P. Finnegan
- Executive Officer of the College on Problems of Drug Dependence and Finnegan Consulting, Philadelphia, PA 19140, USA;
| | - Katie H. K. Chang
- Benten Technologies, 9408 Grant Ave Suite 206, Manassas, VA 20110, USA; (K.R.I.); (S.A.); (A.H.A.); (K.H.K.C.); (T.X.M.)
| | - Tony X. Ma
- Benten Technologies, 9408 Grant Ave Suite 206, Manassas, VA 20110, USA; (K.R.I.); (S.A.); (A.H.A.); (K.H.K.C.); (T.X.M.)
| | - Yukiko Washio
- Substance Use, Gender and Applied Research, RTI International, 3040 E Cornwallis Rd, Durham, NC 27709, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, Temple University Lewis Katz School of Medicine, 3500 N Broad St, Philadelphia, PA 19140, USA
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7
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Pourcyrous M, Elabiad MT, Rana D, Gaston KP, DeBaer L, Dhanireddy R. Racial differences in opioid withdrawal syndrome among neonates with intrauterine opioid exposure. Pediatr Res 2021; 90:459-463. [PMID: 33214673 DOI: 10.1038/s41390-020-01279-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 10/27/2020] [Accepted: 10/29/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND The aim of this study was to investigate the association between race and severe neonatal opioid withdrawal syndrome (NOWS) in infants exposed to intrauterine opioids. METHODS This is a prospective observational study on intrauterine opioid-exposed term infants. Exposure to opioids was based on maternal disclosure, urine, or umbilical cord drug screening. Severe NOWS was defined based on modified Finnegan scoring and the need for pharmacological intervention. RESULTS One hundred and fifty mother-infant pairs, 60 Black and 90 White with history of opioid exposure during pregnancy, were included. More White than Black infants developed NOWS that required pharmacological treatment, 70 vs. 40%: RR = 1.75 (1.25-2.45). In adjusted analysis, there was no significant association between race and the development of severe NOWS in mothers who attended opioid maintenance treatment program (OMTP). However, in mothers who did not attend OMTP, White race remained a significant factor associated with the development of severe NAS, RR = 1.69 (1.06, 2.69). CONCLUSIONS Severe NOWS that required pharmacological intervention was significantly higher in White than in Black infants born to mothers who did not attend OMTP. Larger studies are needed to evaluate the association between social as well as genetic factors and the development of NOWS. IMPACT There is a significant association between race and development of severe NOWS.
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Affiliation(s)
- Massroor Pourcyrous
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA. .,Department of Obstetrics & Gynecology, University of Tennessee Health Science Center, Memphis, TN, USA. .,Department of Physiology, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Mohamad T Elabiad
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Divya Rana
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kan P Gaston
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Linda DeBaer
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ramasubbareddy Dhanireddy
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Obstetrics & Gynecology, University of Tennessee Health Science Center, Memphis, TN, USA
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Flanagan KE, Lal K, Blankenship K, Gorji N, Rork J, Wiss K. Nail disease in neonatal abstinence syndrome. Pediatr Dermatol 2021; 38:787-793. [PMID: 34047407 DOI: 10.1111/pde.14632] [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: 11/28/2022]
Abstract
BACKGROUND/OBJECTIVES Neonatal abstinence syndrome (NAS) incidence continues to rise in the United States due to increasing opioid use disorder in pregnancy. While cutaneous excoriations have been noted in NAS, there is a paucity of literature regarding abnormal nail findings in NAS. METHODS A retrospective, observational case series was conducted of twelve patients with NAS and abnormal nail findings who were admitted to the neonatal intensive care unit between January 1, 2018, and May 1, 2020. RESULTS Twelve neonates (10 male, 2 female, mean gestational age at birth 38.1 weeks) with NAS diagnosis and abnormal nail findings were identified between January 1, 2018, and May 1, 2020. NAS was diagnosed by elevated Modified Finnegan Neonatal Abstinence Syndrome Tool (M-FNAST) scores. All patients required pharmacologic treatment for NAS with seven (58.3%) requiring phenobarbital in addition to first-line morphine. Common nail findings included periungual erythema, yellow crusting, desquamation of the proximal and/or distal lateral nail folds and sheared distal nail edges. Two patients (16.7%) required antibiotic treatment for paronychia. Peak M-FNAST scores were positively correlated with number of abnormal nail findings (r = .58, P = .047). CONCLUSIONS Twelve neonates with severe NAS demonstrated similar nail abnormalities, likely secondary to NAS agitation and motor hyperactivity. Nail exams, therefore, are important in the setting of suspected or confirmed NAS to limit continued nail trauma and infection. Our findings also introduce an association between NAS severity and abnormal nail findings, which will require larger studies for further confirmation.
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Affiliation(s)
- Kelly E Flanagan
- Department of Dermatology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Karan Lal
- Department of Dermatology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Kaitlin Blankenship
- Department of Dermatology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Nasim Gorji
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jillian Rork
- Department of Dermatology, Dartmouth College Geisel School of Medicine, Hanover, NH, USA
| | - Karen Wiss
- Department of Dermatology, University of Massachusetts Medical School, Worcester, MA, USA.,Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, USA
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Ponder KL, Egesdal C, Kuller J, Joe P. Project Console: a quality improvement initiative for neonatal abstinence syndrome in a children's hospital level IV neonatal intensive care unit. BMJ Open Qual 2021; 10:bmjoq-2020-001079. [PMID: 33941537 PMCID: PMC8098972 DOI: 10.1136/bmjoq-2020-001079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 04/10/2021] [Accepted: 04/19/2021] [Indexed: 12/04/2022] Open
Abstract
Objective To improve care for infants with neonatal abstinence syndrome. Design Infants with a gestational age of ≥35 weeks with prenatal opioid exposure were eligible for our quality improvement initiative. Interventions in our Plan–Do–Study–Act cycles included physician consensus, re-emphasis on non-pharmacological treatment, the Eat Sleep Console method to measure functional impairment, morphine as needed, clonidine and alternative soothing methods for parental unavailability (volunteer cuddlers and automated sleeper beds). Pre-intervention and post-intervention outcomes were compared. Results Length of stay decreased from 31.8 to 10.5 days (p<0.0001) without an increase in readmissions. Composite pharmacotherapy exposure days decreased from 28.7 to 5.5 (p<0.0001). This included reductions in both morphine exposure days (p<0.0001) and clonidine exposure days (p=0.01). Fewer infants required pharmacotherapy (p=0.02). Conclusions Our study demonstrates how a comprehensive initiative can improve care for infants with neonatal abstinence syndrome in an open-bay or a high-acuity neonatal intensive care unit when rooming-in is not available or other comorbidities are present.
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Affiliation(s)
- Kathryn L Ponder
- Neonatology, UCSF Benioff Children's Hospital Oakland, Oakland, California, USA
| | - Charles Egesdal
- Pediatrics, UCSF Benioff Children's Hospital Oakland, Oakland, California, USA
| | - Joanne Kuller
- Neonatology, UCSF Benioff Children's Hospital Oakland, Oakland, California, USA
| | - Priscilla Joe
- Neonatology, UCSF Benioff Children's Hospital Oakland, Oakland, California, USA
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Assessing the Burden of Neonatal Abstinence Syndrome: Validation of ICD-9-CM Data, Florida, 2010-2011. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2021; 26:E1-E8. [PMID: 31765350 DOI: 10.1097/phh.0000000000000897] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
CONTEXT On October 1, 2015, the United States transitioned from using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) to ICD-10-CM. Continuing to monitor the burden of neonatal abstinence syndrome (NAS) after the transition presently requires use of data dependent on ICD-9-CM coding to enable trend analyses. Little has been published on the validation of using ICD-9-CM codes to identify NAS cases. OBJECTIVE To assess the validity of hospital discharge data (HDD) from selected Florida hospitals for passive NAS surveillance, based on ICD-9-CM codes, which are used to quantify baseline prevalence of NAS. DESIGN We reviewed infant and maternal data for all births at 3 Florida hospitals from 2010 to 2011. Potential NAS cases included infants with ICD-9-CM discharge codes 779.5 and/or 760.72 in linked administrative data (ie, HDD linked to vital records) or in unlinked HDD and infants identified through review of neonatal intensive care unit admission logs or inpatient pharmacy records. Confirmed infant cases met 3 clinician-proposed criteria. Sensitivity and positive predictive value were calculated to assess validity for the 2 ICD-9-CM codes, individually and combined. RESULTS Of 157 confirmed cases, 134 with 779.5 and/or 760.72 codes were captured in linked HDD (sensitivity = 85.4%) and 151 in unlinked HDD (sensitivity = 96.2%). Positive predictive value was 74.9% for linked HDD and 75.5% for unlinked HDD. For either HDD types, the single 779.5 code had the highest positive predictive value (86%), lowest number of false positives, and good to excellent sensitivity. CONCLUSIONS Passive surveillance using ICD-9-CM code 779.5 in either linked or unlinked HDD identified NAS cases with reasonable validity. Our work supports the use of ICD-9-CM code 779.5 to assess the baseline prevalence of NAS through 2015.
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11
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Leiner C, Cody T, Mullins N, Ramage M, Ostrach BMM. "The elephant in the room;" a qualitative study of perinatal fears in opioid use disorder treatment in Southern Appalachia. BMC Pregnancy Childbirth 2021; 21:143. [PMID: 33596843 PMCID: PMC7890815 DOI: 10.1186/s12884-021-03596-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 01/27/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Diagnoses of perinatal opioid use disorder (OUD) continue to rise in the United States. Patients and providers report obstacles to OUD treatment access. Difficulties include legal ambiguity related to Social Services notification requirements following a birth to people using opioids or in medication-assisted treatment for OUD. METHODS Through semi-structured interviews, participant-observation, and a focus group conducted in a mostly rural, region of the Southern United States (where perinatal OUD is more prevalent), patients' and providers' perspectives about perinatal substance use treatment were initially sought for a larger study. The findings presented here are from a subset analysis of patients' experiences and perspectives. Following ethics review and exemption determination, a total of 27 patient participants were opportunistically, convenience, and/or purposively sampled and recruited to participate in interviews and/or a focus group. Data were analyzed using modified Grounded Theory. RESULTS When asked about overall experiences with and barriers to accessing perinatal substance use treatment, 11 of 27 participants reported concerns about Social Services involvement resulting from disclosure of their substance use during pregnancy. In the subset analysis, prevalent themes were Fears of Social Services Involvement, Preparation for Delivery, and Providers Addressing Fears. CONCLUSIONS Perinatal OUD patients may seek substance use treatment with existing fears of Social Services involvement. Patients appreciate providers' efforts to prepare them for this potential reality. Providers should become aware of how their own hospital systems, counties, states, and countries interpret laws governing notification requirements. By becoming aware of patients' fears, providers can be ready to discuss the implications of Social Services involvement, promote patient-centered decision-making, and increase trust.
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Affiliation(s)
- Catherine Leiner
- UNC School of Medicine, 321 S Columbia St, Chapel Hill, NC, 27516321, USA
| | - Tamara Cody
- Mountain Area Health Education Center, 119 Hendersonville Rd, Asheville, NC, 28803, USA
| | - Nathan Mullins
- Mountain Area Health Education Center, 119 Hendersonville Rd, Asheville, NC, 28803, USA
| | - Melinda Ramage
- Mountain Area Health Education Center, 119 Hendersonville Rd, Asheville, NC, 28803, USA
| | - Bayla M M Ostrach
- Department of Research, UNC Health Sciences at MAHEC, 121 Hendersonville Road, Asheville, NC, 28803, USA.
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Kushnir A, Garretson C, Mariappan M, Stahl G. Use of Phenobarbital to Treat Neonatal Abstinence Syndrome From Exposure to Single vs. Multiple Substances. Front Pediatr 2021; 9:752854. [PMID: 35174112 PMCID: PMC8841756 DOI: 10.3389/fped.2021.752854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 12/21/2021] [Indexed: 11/17/2022] Open
Abstract
Drug use in pregnancy is a major public health issue. Intrauterine exposure to opioids alone or in addition to other substances may lead to neonatal abstinence syndrome (NAS). Little consensus exists on optimal therapy, especially for those exposed to multiple drugs. We aim to determine whether the use of opioids alone vs. in combination with phenobarbital will affect short-term neonatal outcomes. This retrospective review of infants admitted to the neonatal intensive care unit (NICU) included newborns ≥35 weeks of gestation exposed to opioids, or multiple substances including opioids, in utero. Treatment with opioids alone, and addition of phenobarbital as initial therapy vs. rescue, was evaluated. Out of 182 newborns, 54 (30%) were exposed to methadone alone vs. 128 (70%) to multiple drugs. Length of stay (LOS) in the hospital was not significantly affected (p = 0.684) by single vs. multiple drug exposure in utero. Treatment of NAS with opioid alone resulted in significantly shorter LOS (27 days), as compared to those treated with opioid and phenobarbital (45 days, p < 0.001). LOS was further prolonged in those treated with phenobarbital as a "rescue" medication in addition to an opioid (49 days, p < 0.0001). There was a significant increase in LOS and duration of opioid treatment for all infants treated with phenobarbital, both in those exposed to opioids alone, and to multiple substances in utero.
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Affiliation(s)
- Alla Kushnir
- Division of Neonatology, Department of Pediatric, Cooper University Hospital, Camden, NJ, United States.,Department of Pediatric, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Cynthia Garretson
- Ambulatory Clinical Practice, Cooper University Hospital, Cherry Hill, NJ, United States
| | - Maheswari Mariappan
- Division of Neonatology, Department of Pediatric, Cooper University Hospital, Camden, NJ, United States
| | - Gary Stahl
- Department of Pediatric, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States
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Janson JA, Wasylewicz ATM, Eijkemans M, Kerskes M. Citalopram intoxication in four week old infant. BMC Pediatr 2020; 20:552. [PMID: 33287753 PMCID: PMC7722423 DOI: 10.1186/s12887-020-02439-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 11/19/2020] [Indexed: 11/16/2022] Open
Abstract
Background In contrast to intoxications in toddlers which can be due to accidental ingestions, many intoxications in infants are due to medication errors. To our knowledge, this is the first case report of a citalopram intoxication in an infant, and may offer new insight on possible screening methods for intoxication as well as pharmacokinetics of citalopram in small infants. Case presentation This case report describes an unintentional citalopram intoxication in a 4 week old infant due to a vitamin D drops ‘look alike’ error. The infant showed extreme jitteriness and opisthotonus at presentation, as well as prolonged signs of gastro-oesophageal reflux. No cardiac rhythm disturbances or convulsions were seen. The clinical course combined with Finnegan scores was correlated to and supported by pharmacokinetic and pharmacokinetic data of citalopram in the patient. Conclusions Using Finnegan scores in general pediatric practice could help objectify follow-up of acute intoxications in young infants with neurological symptoms. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-020-02439-5.
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Affiliation(s)
- Jo-Anne Janson
- Pediatrics, Maastricht UMC+, Maastricht, The Netherlands
| | | | - Marianne Eijkemans
- Pediatrics, Catharina Hospital, Michelangelolaan 2, 5623, EJ Eindhoven, The Netherlands.
| | - Marieke Kerskes
- Pharmacology, Catharina Hospital, Eindhoven, The Netherlands
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Safety, Feasibility, and Effectiveness of Weighted Blankets in the Care of Infants With Neonatal Abstinence Syndrome: A Crossover Randomized Controlled Trial. Adv Neonatal Care 2020; 20:384-391. [PMID: 32868588 DOI: 10.1097/anc.0000000000000724] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Nurses are caring for increasing numbers of infants diagnosed with neonatal abstinence syndrome (NAS). The recommended initial line of treatment to alleviate NAS symptoms includes nonpharmacologic interventions; however, there is little rigorous evidence on the effectiveness of nonpharmacologic interventions. PURPOSE The purpose of this study was to assess the safety, feasibility, and effectiveness of weighted blankets in the care of NAS infants. METHODS This pilot study was a crossover randomized nonblinded controlled trial conducted at a level III neonatal intensive care unit. Infants' care included 30-minute sessions utilizing either a nonweighted or weighted blanket, with infants serving as their own controls. RESULTS A total of 16 patients were enrolled for a total of 67 weighted blanket sessions. To address safety, no adverse events were observed, the weighted blankets were never removed due to infant distress, and infants experienced no significant temperature change. To address feasibility, 94% of approached mothers were receptive to the use of weighted blankets and staff reported no obstacles to using the blanket. Finally, to assess effectiveness, there was a significant decrease in the infant's heart rate and Finnegan score when a weighted blanket was used. There was no significant change in respiratory rate with the use of a weighted blanket. IMPLICATIONS FOR PRACTICE Weighted blankets may be safe, feasible, and effective in decreasing NAS symptoms. IMPLICATIONS FOR RESEARCH Larger studies are needed to thoroughly study the use of weighted blankets in this population and examine additional outcomes, such as need for pharmacologic intervention, length of hospital stay, and cost of hospital stay.
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Goyal NK, McAllister J. Hospital Care of Opioid-Exposed Newborns: Clinical and Psychosocial Challenges. J Hosp Med 2020; 15:613-618. [PMID: 32118559 DOI: 10.12788/jhm.3369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 12/06/2019] [Indexed: 11/20/2022]
Abstract
In the past two decades, the incidence of neonatal abstinence syndrome (NAS) has risen fivefold, mirroring the rise of opioid use disorder (OUD) among pregnant women. The resulting increases in length of stay and neonatal intensive care utilization are associated with higher hospital costs, particularly among Medicaid-financed deliveries. Pregnant women with OUD require comprehensive medical and psychosocial evaluation and management; this combined with medication-assisted treatment is critical to optimize maternal and newborn outcomes. Multidisciplinary collaboration and standardized approaches to screening for intrauterine opioid exposure, evaluation and treatment of NAS, and discharge planning are important for clinical outcomes and may improve maternal experience of care.
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Affiliation(s)
- Neera K Goyal
- Department of Pediatrics, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
- Nemours/AI duPont Hospital for Children, Wilmington, Delaware
| | - Jennifer McAllister
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Noort BMV, Timme A, Watrin-Avino L, Nagel M, Bührer C, Hüseman D, Siedentopf JP, Wiefel A, Leupold H, Winter S. Retrospektive Evaluation eines interdisziplinären Nachsorgeangebots für suchtmittelexponierte Neugeborene. KINDHEIT UND ENTWICKLUNG 2020. [DOI: 10.1026/0942-5403/a000312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Zusammenfassung. Pränatale Suchtmittelexposition ist ein großer Risikofaktor für organische, neurologische und psychische Entwicklungsstörungen. In der Gesamtstichprobe ( N = 84) erfolgte auf Grund der Schwere der Störung bei fast der Hälfte der Kinder eine medikamentöse Behandlung des Neonatalen Entzugssyndroms. 56 Familien nahmen das Nachsorgeangebot im Rahmen einer Kooperation zwischen Geburtsmedizin, Neonatologie und Kinder- und Jugendpsychiatrie wahr (BK-Gruppe) und 28 erschienen nicht (N-Gruppe). In der N-Gruppe nahmen die Mütter präpartal häufiger Substitutionsmittel ein ( p=0,02). Kinder aus der BK-Gruppe erhielten häufiger Unterstützung durch Jugendhilfe (22 %) und wurden seltener (46 %) in den elterlichen Haushalt entlassen ( p<0,05). Bei über 80 % der Säuglinge wurde eine Regulationsstörung diagnostiziert. Nach unseren Erfahrungen besteht aufgrund der Vielzahl von Entwicklungsrisiken und psychosozialen Belastungen eine dringliche Indikation zur interdisziplinären Diagnostik und Behandlung aller dieser Neugeborenen.
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Affiliation(s)
| | - Anja Timme
- Charité – Universitätsmedizin Berlin, Sozialpädiatrisches Zentrum, Abteilung Kinder- und Jugendpsychiatrie, Baby- und Kleinkindsprechstunde
| | - Laura Watrin-Avino
- Charité – Universitätsmedizin Berlin, Sozialpädiatrisches Zentrum, Abteilung Kinder- und Jugendpsychiatrie, Baby- und Kleinkindsprechstunde
| | - Manuela Nagel
- Charité – Universitätsmedizin Berlin, Klinik für Geburtsmedizin, Ambulanz für Suchterkrankungen und Infektionen in der Schwangerschaft
| | | | - Dieter Hüseman
- Klinik für Kinder- und Jugendmedizin, Klinikum Barnim GmbH, Werner Forßmann Krankenhaus, Eberswalde
| | - Jan-Peter Siedentopf
- Charité – Universitätsmedizin Berlin, Klinik für Geburtsmedizin, Ambulanz für Suchterkrankungen und Infektionen in der Schwangerschaft
| | - Andreas Wiefel
- Charité – Universitätsmedizin Berlin, Sozialpädiatrisches Zentrum, Abteilung Kinder- und Jugendpsychiatrie, Baby- und Kleinkindsprechstunde
| | - Heike Leupold
- Charité – Universitätsmedizin Berlin, Sozialpädiatrisches Zentrum, Abteilung Kinder- und Jugendpsychiatrie, Baby- und Kleinkindsprechstunde
| | - Sibylle Winter
- Charité – Universitätsmedizin Berlin, Klinik für Psychiatrie, Psychosomatik und Psychotherapie des Kindes- und Jugendalters
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Effects of reflexology on child health: A systematic review. Complement Ther Med 2020; 50:102364. [PMID: 32444044 DOI: 10.1016/j.ctim.2020.102364] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 03/02/2020] [Accepted: 03/02/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND It is known that the parents of one of every two children who need health care seek at least one complementary health-care approach. Reflexology, which is one of these, increases well-being while maintaining the continuity of homeostasis. As studies with children are limited, there is a need for evidence that includes the positive as well as the negative effects of reflexology that can be transferred to clinical practice and recommendations for future studies. AIM The aim of this study was to examine the effects of reflexology on child health by systematically summarizing the results obtained. METHOD In this study, which was structured as a systematic review, data were obtained by scanning CINAHL, Cochrane Library, Academic Search Complete, WoS, Scopus, Science Direct, PubMed, and ProQuest. According to MeSH terminology, (zone therapy OR reflexology OR foot massage OR hand massage) AND (pediatrics OR child OR infant OR baby) were used. Randomized controlled studies (RCTs), systematic reviews, and meta-analyses conducted with a pediatric population and accessible in English and full text up to 07.08.2019 (with no time limitation) were included. Exclusion criteria for the present study included applying a massage procedure different from reflexology, the inclusion of an adult sample, or publication of the article in a predatory journal. The Cochrane guidelines (Handbook for Systematic Reviews of Interventions Version 5.2.0, 2017) were applied and the article reported on according to the PRISMA checklist. RESULTS In all six of the RCTs, which included a total of 277 infants and children, the only method used was foot reflexology. Regarding the results of nine investigated outcomes, reflexology was found to be effective in infancy for reducing pain level and regulating heart rate, for increasing oxygen saturation, for relieving infantile colic symptoms, and neonatal abstinence symptoms. Reflexology was also found to decrease spasticity and improve motor skills in children with cerebral palsy, but it failed to produce positive change in regard to constipation and quality of life. Four of the studies were performed in a nursing context, one in midwifery, and one in physiotherapy. CONCLUSION As a common result of the studies conducted with different sample groups, it is possible that reflexology had positive effects on children. However, the absence of standardization related to reflexology, inadequate use of a study protocol and guidelines, the heterogeneity of the data, and the determination that half the studies were conducted with high-risk groups according to the bias analysis with RoB 2.0 indicate that it is too soon to generalize the results. Well-structured, randomized controlled double-blind trials are required.
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The Parental Experience of Newborns With Neonatal Abstinence Syndrome Across Inpatient Care Settings: A Qualitative Study. J Addict Med 2020; 14:e183-e187. [DOI: 10.1097/adm.0000000000000624] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Treatment of opioid withdrawal in neonates with morphine, phenobarbital, or chlorpromazine: a randomized double-blind trial. Eur J Pediatr 2020; 179:141-149. [PMID: 31691849 PMCID: PMC6942588 DOI: 10.1007/s00431-019-03486-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 09/24/2019] [Accepted: 09/24/2019] [Indexed: 01/09/2023]
Abstract
Three suitable compounds (morphine, chlorpromazine, and phenobarbital) to treat neonatal abstinence syndrome were compared in a prospective multicenter, double-blind trial. Neonates exposed to opioids in utero were randomly allocated to one of three treatment groups. When a predefined threshold of a modified Finnegan score was reached, treatment started and increased stepwise until symptoms were controlled. If symptoms could not be controlled with the predefined maximal dose of a single drug, a second drug was added. Among 143 infants recruited, 120 needed pharmacological treatment. Median length of treatment for morphine was 22 days (95% CI 18 to 33), for chlorpromazine 25 days (95% CI 21 to 34), and for phenobarbital 32 days (95% CI 27 to 38) (p = ns). In the morphine group, only 3% of infants (1/33) needed a second drug; in the chlorpromazine group, this proportion was 56% (24/43), and in the phenobarbital group 30% (13/44).Conclusion: None of the drugs tested for treating neonatal abstinence syndrome resulted in a significantly shorter treatment length than the others. As morphine alone was able to control symptoms in almost all infants, it may be preferred to the two other drugs but should still be tested against more potent opioids such as buprenorphine.Trial registration: At ClinicalTrials.gov NCT02810782 (registered retrospectively).What is Known:• Neonates exposed to opiates in utero and presenting with withdrawal symptoms should first be treated by non-pharmacological supportive measures.• In those who fail, drugs have to be given, but there is controversy which drug is best.What is New:• Among three candidates, morphine, chlorpromazine and phenobarbital, none resulted in significantly shorter treatment time.• As morphine alone was able to control symptoms in almost all infants, it may be preferred to the two other drugs.
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MacMillan KDL. Neonatal Abstinence Syndrome: Review of Epidemiology, Care Models, and Current Understanding of Outcomes. Clin Perinatol 2019; 46:817-832. [PMID: 31653310 DOI: 10.1016/j.clp.2019.08.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The incidence of neonatal abstinence syndrome owing to prenatal opioid exposure has grown rapidly in recent decades and it disproportionately affects rural, non-white, and public insurance-dependent populations. Treatment consists of pharmacologic and nonpharmacologic interventions with wide variability in approaches across the United States. Standardizing clinical assessment, minimizing unnecessary interruptions, and prioritizing nonpharmacologic and family-centered care seems to improve hospital outcomes. Neonatal abstinence syndrome may have long-term developmental and biological effects, but understanding is limited owing in part confounding biosocial factors. Early intervention and longitudinal support of the infant and family promote better outcomes.
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Affiliation(s)
- Kathryn Dee Lizcano MacMillan
- Division of Neonatology and Newborn Medicine, Massachusetts General Hospital for Children, Good Samaritan Medical Center, 55 Fruit Street, Founders 5-530, Boston, MA 02114, USA; Division of Pediatric Hospital Medicine, Massachusetts General Hospital for Children, Good Samaritan Medical Center, 55 Fruit Street, Founders 5-530, Boston, MA 02114, USA.
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21
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The effect of maternal antidepressants on third trimester uteroplacental hemodynamics and the neonatal abstinence syndrome: a retrospective cohort study. Arch Womens Ment Health 2019; 22:791-797. [PMID: 30798375 DOI: 10.1007/s00737-019-00954-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 02/05/2019] [Indexed: 10/27/2022]
Abstract
The objective of this study is to determine whether maternal antidepressant use during pregnancy influences uteroplacental hemodynamics, thereby affecting fetal growth and gestational age at delivery. The secondary aim was to determine the incidence of neonatal abstinence syndrome (NAS) among infants exposed to antidepressant medications. The charts of women who received obstetrical care and had a history of depression from January 2014 to December 2016 at Mount Sinai Hospital in Toronto, Canada, were reviewed. Exclusion criteria were substance abuse; narcotic or lithium use at the time of delivery.In total, 205 women met the inclusion criteria (92 took antidepressants; 113 women did not). There were no significant differences in umbilical artery pulsatility index (PI), gestational age at delivery, or birth weight when comparing women based on antidepressant use. A small proportion (18%) of neonates had mild withdrawal symptoms; one baby had a score (≥ 8) consistent with severe NAS. In women with a history of depression, there was no difference in uteroplacental hemodynamics as measured by third trimester Doppler ultrasonography when comparing women who took antidepressant medication versus those who did not. The large majority of babies who were exposed to antidepressants in utero did not show withdrawal symptoms. These results lend support for the relative safety of antidepressants during pregnancy.
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22
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Comparing the effects of auricular seed acupressure and foot reflexology on neonatal abstinence syndrome: A modified double blind clinical trial. Complement Ther Clin Pract 2019; 36:72-76. [PMID: 31383448 DOI: 10.1016/j.ctcp.2019.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 05/29/2019] [Accepted: 06/07/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND The neonates of addicted women are at risk for neonatal abstinence syndrome. This study aimed to compare the effects of auricular seed acupressure and foot reflexology on neonatal abstinence syndrome among the neonates of addicted women. METHODS Thirty one neonates of addicted women were purposively recruited and randomly allocated through coin flipping to receive either foot reflexology then seed acupressure or seed acupressure then foot reflexology. Interventions were performed in two successive days with a 12-h washout interval. Foot reflexology was applied for 15 min to the first horizontal zone of the sole while seed acupressure was applied for 24 h through attaching acupuncture-specific ear seeds to the posterior surface of the auricle on the SJ 17 acupoint. The symptoms of abstinence syndrome were assessed using Finnegan Neonatal Abstinence Scoring System before and after foot reflexology, and before, 15 min, and 24 h after the onset of the seed acupressure intervention. Symptom assessment was done by a research assistant who was blind to the study intervention. FINDINGS The mean score of abstinence symptoms for the foot reflexology intervention significantly reduced from 10.32 ± 2.10 at pretest to 7.87 ± 2.04 at posttest (P < 0.001). Moreover, the mean score of abstinence symptoms for the seed acupressure intervention significantly reduced from 9.70 ± 2.10 to 8.70 ± 1.46 at the first posttest (P = 0.007) and 7.32 ± 1.42 at the second posttest (P < 0.001). The change in the mean score of the foot reflexology intervention was significantly greater than the change in the mean score at the first seed acupressure posttest (P < 0.001) but did not significantly differ from the change in the second seed acupressure posttest (P = 0.880). CONCLUSION Both foot reflexology and auricular seed acupressure has significant effects on abstinence symptoms. Of course, 15-min seed acupressure is less effective than 15-min foot reflexology, while 24-h seed acupressure is as effective as 15-min foot reflexology in alleviating abstinence symptoms.
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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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Whalen BL, Holmes AV, Blythe S. Models of care for neonatal abstinence syndrome: What works? Semin Fetal Neonatal Med 2019; 24:121-132. [PMID: 30926259 DOI: 10.1016/j.siny.2019.01.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Opioid use disorders and the prescription of long-acting medications for their treatment have increased dramatically over the last decade among pregnant women. Newborns who experience prolonged in utero opioid exposure may develop neonatal abstinence syndrome (NAS). Until recently, much of the focus on improving care for NAS has been on pharmacologically-based care models. Recent studies have illustrated the benefits of rooming-in and parental presence on NAS outcomes. Single center Quality Improvement (QI) initiatives demonstrate the benefits of non-pharmacologic care bundles and symptom prioritization in decreasing the proportion of infants pharmacologically treated and length of hospital stay. Little remains known about the impact of these varied cared models on maternal-infant attachment and mental health. In this review article, we will propose an optimal model of care to improve short- and long-term outcomes for newborns, their mothers and families, and perinatal care systems.
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Affiliation(s)
- Bonny L Whalen
- Geisel School of Medicine at Dartmouth, Children's Hospital at Dartmouth-Hitchcock, Dartmouth-Hitchcock Medical Center, DHMC Pediatrics, One Medical Center Dr., Lebanon, NH, 03756, USA.
| | - Alison V Holmes
- Geisel School of Medicine at Dartmouth, Children's Hospital at Dartmouth-Hitchcock, Dartmouth-Hitchcock Medical Center, The Dartmouth Institute, DHMC Pediatrics, One Medical Center Dr, Lebanon, NH, 03756, USA.
| | - Stacy Blythe
- School of Nursing and Midwifery, Western Sydney University, Translational Health Research Institute (THRI), Locked Bag 1797, Western Sydney University, Penrith, NSW, 2751, Australia.
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Abstract
Neonates exposed prenatally to opioids will often develop a collection of withdrawal signs known as neonatal abstinence syndrome (NAS). The incidence of NAS has substantially increased in recent years placing an increasing burden on the healthcare system. Traditional approaches to assessment and management have relied on symptom-based scoring tools and utilization of slowly decreasing doses of medication, though newer models of care focused on non-pharmacologic interventions and rooming-in have demonstrated promise in reducing length of hospital stay and medication usage. Data on long-term outcomes for both traditional and newer approaches to care of infants with NAS is limited and an important area of future research. This review will examine the history, incidence and pathophysiology of NAS. We will also review diagnostic screening approaches, scoring tools, differing management approaches and conclude with recommendations for continued work to improve the care of infants with NAS.
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Affiliation(s)
- Matthew Grossman
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, United States.
| | - Adam Berkwitt
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, United States
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26
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Schiff DM, Grossman MR. Beyond the Finnegan scoring system: Novel assessment and diagnostic techniques for the opioid-exposed infant. Semin Fetal Neonatal Med 2019; 24:115-120. [PMID: 30738754 PMCID: PMC6451877 DOI: 10.1016/j.siny.2019.01.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Infants with in-utero opioid exposure are most commonly assessed using the Finnegan Neonatal Abstinence Scoring System (FNASS) or a modified version of that tool. Traditionally, the purpose of these tools has been to characterize the extent of withdrawal signs to guide the pharmacologic treatment for infants with neonatal opioid withdrawal syndrome (NOWS). In the past decade however, in response to some of the limitations of the FNASS tool, there has been an increasing emphasis on developing novel assessment tools not based on the FNASS in addition to the promotion of non-pharmacologic treatment options as the first line treatment for infants with opioid exposure. Additionally, several prediction tools that may be useful in determining which patients are at high or low risk for receiving pharmacologic therapy have been developed. In this review, we will evaluate the clinical utility of these novel tools and will consider new avenues for future research.
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Affiliation(s)
- Davida M Schiff
- Division of General Academic Pediatrics, MassGeneral Hospital for Children, 125 Nashua St #8630, USA.
| | - Matthew R Grossman
- Yale School of Medicine, Department of Pediatrics, 333 Cedar St., PO Box 208064, New Haven, CT, 06520-8064, USA.
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27
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Mangat AK, Schmölzer GM, Kraft WK. Pharmacological and non-pharmacological treatments for the Neonatal Abstinence Syndrome (NAS). Semin Fetal Neonatal Med 2019; 24:133-141. [PMID: 30745219 PMCID: PMC6451887 DOI: 10.1016/j.siny.2019.01.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Neonatal abstinence syndrome is defined by signs and symptoms of withdrawal that infants develop after intrauterine maternal drug exposure. All infants with documented in utero opioid exposure, or a high pre-test probability of exposure should have monitoring with a standard assessment instrument such as a Finnegan Score. A Finnegan score of >8 is suggestive of opioid exposure, even in the absence of declared use during pregnancy. At least half of infants in most locales can be treated without the use of pharmacologic means. For this reason, symptom scores will drive the decision for pharmacologic therapy. Nevertheless, all infants, regardless of initial manifestations, should be first be managed with non-pharmacologic approaches which in turn, should not be considered as the sole alternative to drug therapy, but rather, as the base upon which all patients are treated. Those who continue to have symptoms despite supportive care should be pharmacologically treated, which in the most severe cases, is life-saving.
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Affiliation(s)
- A K Mangat
- Faculty of Science, University of Alberta, Edmonton, Alberta, Canada; Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - G M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
| | - W K Kraft
- Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, PA, USA
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Benahmed-Canat A, Plaisant F, Riche B, Rabilloud M, Canat G, Paret N, Claris O, Kassai B, Nguyen KA. Postsurgery analgesic and sedative drug use in a French neonatal intensive care unit: A single-center retrospective cohort study. Arch Pediatr 2019; 26:145-150. [PMID: 30885601 DOI: 10.1016/j.arcped.2019.02.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 12/15/2018] [Accepted: 02/09/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To describe pain assessment, the pattern of analgesic and sedative drug use, and adverse drug reactions in a neonatal intensive care unit (NICU) during the postsurgery phase. METHOD Demographic characteristics, pain scores, and drug use were extracted and analyzed from electronic patient medical files for infants after surgery, admitted consecutively between January 2012 and June 2013. RESULT One hundred and sixty-eight infants were included. Acute (DAN score) and prolonged (EDIN score) pain assessment scores were used in 79% and 64% of infants, respectively, on the 1st day. This percentage decreased over the 7 days following surgery. The weekly average scores postsurgery were 2/15 (±2.2) for the EDIN score and 1.6/10 (±2.0) for the DAN score. The rates of pain control were 88% for the EDIN and 72% for the DAN. The most prescribed opiate drug was fentanyl (98 patients; 58%) with an average dose of 1.8 (±0.6) μg/kg/h. Midazolam was used in 95 patients (56%), with an average dose of 35 (±14) μg/kg/h. A bolus was administered in 7% (±7.4) of the total dose for fentanyl and 8% (±9.3) for midazolam. Similar doses were used in term and preterm neonates. Of 118 patients receiving fentanyl and/or midazolam, 40% presented urinary retention, 28% a weaning syndrome. Paracetamol (155 patients; 92%) and nalbuphine (55 patients; 33%) were the other medications most often prescribed. CONCLUSION The off-label use of fentanyl and midazolam was necessary to treat pain after surgery. Pain assessment should be conducted for all neonates in order to optimize their treatment. Research on analgesic and sedative medicine in vulnerable neonates seems necessary to standardize practices and reduce adverse drug reactions.
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Affiliation(s)
- A Benahmed-Canat
- Department of Neonatology, hôpital Femme-Mère-Enfant, Hospices Civils de Lyon, Lyon, 69500 Bron, France
| | - F Plaisant
- Department of Neonatology, hôpital Femme-Mère-Enfant, Hospices Civils de Lyon, Lyon, 69500 Bron, France
| | - B Riche
- Department of Biostastistics, Hospices Civils de Lyon, Lyon, 69500 Bron, France
| | - M Rabilloud
- Department of Biostastistics, Hospices Civils de Lyon, Lyon, 69500 Bron, France
| | - G Canat
- Liberal general practitioner, France
| | - N Paret
- UMR 5558, LBBE, Department of Pharmacotoxicology, Université de Lyon 1, Hospices Civils de Lyon, Lyon, 69500 Bron, France
| | - O Claris
- Department of Neonatology, hôpital Femme-Mère-Enfant, Hospices Civils de Lyon, Lyon, 69500 Bron, France; EA 4129, Université de Lyon 1, France
| | - B Kassai
- UMR 5558, LBBE, Department of Pharmacotoxicology, Université de Lyon 1, Hospices Civils de Lyon, Lyon, 69500 Bron, France
| | - K A Nguyen
- Department of Neonatology, hôpital Femme-Mère-Enfant, Hospices Civils de Lyon, Lyon, 69500 Bron, France; UMR 5558, LBBE, Department of Pharmacotoxicology, Université de Lyon 1, Hospices Civils de Lyon, Lyon, 69500 Bron, France.
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Limjoco J, Zawadzki L, Belden M, Eickhoff J, Ikonomidou C. Amplitude-integrated EEG use in neonatal abstinence syndrome: a pilot study. J Matern Fetal Neonatal Med 2019; 33:3565-3570. [PMID: 30720377 DOI: 10.1080/14767058.2019.1579190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: Though central nervous system irritability is a well-established consequence of neonatal drug withdrawal, brain function in infants with neonatal abstinence syndrome (NAS) is not well understood. Amplitude-integrated electroencephalography (aEEG) is a bedside tool used for monitoring brain activity and seizures. We describe the prevalence of abnormal aEEG background patterns in infants with NAS.Methods: In this pilot, observational study primary outcomes were aEEG findings, Finnegan scores, and length of hospital stay in NAS patients. Subjects underwent an initial aEEG and a repeat study following pharmacologic treatment. Two independent reviewers analyzed aEEGs post discharge.Results: Six out of nine infants had abnormal aEEGs demonstrating lack of sleep-wake cycling (SWC) (50%), discontinuity (41.7%), and low voltage (8.3%). Seizures were not detected. NAS scores were lower for infants with continuous aEEGs versus those whose aEEGs were not continuous (5.83 versus 9.17; p = .054). Length of stay was 7.8 ± 4.4 days in infants with continuous aEEGs versus 26 ± 10.5 days in infants without continuous aEEGs (p = .003).Conclusions: Infants exposed to opioids in utero are at increased risk for discontinuity and abnormal SWC detectable on aEEG. Infants with abnormal aEEGs are more likely to have higher NAS scores, require pharmacologic treatment and have longer lengths of stay.
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Affiliation(s)
- Jamie Limjoco
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Lucyna Zawadzki
- Department of Neurology, Akron Children's Hospital, Akron, OH, USA
| | - Meghan Belden
- Department of Pharmacy, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Jens Eickhoff
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Chrysanthy Ikonomidou
- Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Capino AC, Johnson PN, Williams PK, Anderson MP, Bedwell S, Miller JL. Pilot Study Comparing Modified Finnegan Scoring Versus Adjusted Scoring System for Infants With Iatrogenic Opioid Abstinence Syndrome After Cardiothoracic Surgery. J Pediatr Pharmacol Ther 2019; 24:148-155. [PMID: 31019408 DOI: 10.5863/1551-6776-24.2.148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To compare the modified Finnegan Scoring System (modified Finnegan) with an Adjusted Scoring System Criteria (adjusted Finnegan) for infants after cardiothoracic surgery with iatrogenic opioid abstinence syndrome (IOAS). METHODS This was a retrospective, observational pilot study. This study was conducted in a tertiary care academic hospital. Infants after cardiothoracic surgery with IOAS transferred between the pediatric intensive care unit and neonatal intensive care unit between January 1, 2014, and January 31, 2016, were included retrospectively. The main outcome variable was to compare the area under the curve for the mean modified Finnegan versus adjusted Finnegan. RESULTS Twenty-five patients were included in the study. Twenty patients with at least 30 scores were included in the final analysis. Overall, the modified Finnegan scores were at least 2 points higher than the adjusted Finnegan. The difference in area under the curve was 34.6 (p < 0.001). CONCLUSIONS Use of the modified Finnegan tool for older infants with IOAS could overestimate withdrawal, leading to unnecessary interventions.
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Lind JN, Ailes EC, Alter CC, Fornoff JE, Brozicevic P, Garcia Saavedra LF, Tomedi LE, Gambatese M, Carroll B, Orantes L, Martin B, Horne AA, Reefhuis J. Leveraging Existing Birth Defects Surveillance Infrastructure to Build Neonatal Abstinence Syndrome Surveillance Systems - Illinois, New Mexico, and Vermont, 2015-2016. MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT 2019; 68:177-180. [PMID: 30789880 PMCID: PMC6385712 DOI: 10.15585/mmwr.mm6807a3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Martins F, Oppolzer D, Santos C, Barroso M, Gallardo E. Opioid Use in Pregnant Women and Neonatal Abstinence Syndrome-A Review of the Literature. TOXICS 2019; 7:E9. [PMID: 30781484 PMCID: PMC6468487 DOI: 10.3390/toxics7010009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 02/10/2019] [Accepted: 02/13/2019] [Indexed: 02/07/2023]
Abstract
Opiate use during pregnancy has been an increasing problem over the last two decades, making it an important social and health concern. The use of such substances may have serious negative outcomes in the newborn, and clinical and cognitive conditions have been reported, including neonatal abstinence syndrome, developmental problems, and lower cognitive performance. These conditions are common when opiates are used during pregnancy, making the prescription of these kinds of drugs problematic. Moreover, the mother may develop opiate addiction, thus, increasing the likelihood of the infant being born with any of those conditions. This paper reviews the use of opiates during pregnancy and focuses mainly on the neonatal abstinence syndrome. First, the commonly prescribed opiates will be identified, namely those usually involved in cases of addiction and/or neonatal abstinence syndrome. Second, published approaches to deal with those problems will be presented and discussed, including the treatment of both the mother and the infant. Finally, we will outline the treatments that are safest and most efficient, and will define future goals, approaches, and research directions for the scientific community regarding this problem.
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Affiliation(s)
- Fábio Martins
- Centro de Investigação em Ciências da Saúde, Faculdade de Ciências da Saúde da Universidade da Beira Interior (CICS-UBI), 6200-506 Covilhã, Portugal.
| | - David Oppolzer
- Centro de Investigação em Ciências da Saúde, Faculdade de Ciências da Saúde da Universidade da Beira Interior (CICS-UBI), 6200-506 Covilhã, Portugal.
| | - Catarina Santos
- Centro de Investigação em Ciências da Saúde, Faculdade de Ciências da Saúde da Universidade da Beira Interior (CICS-UBI), 6200-506 Covilhã, Portugal.
| | - Mário Barroso
- Serviço de Química e Toxicologia Forenses, Instituto de Medicina Legal e Ciências Forenses-Delegação do Sul, 1150-334 Lisboa, Portugal.
| | - Eugenia Gallardo
- Centro de Investigação em Ciências da Saúde, Faculdade de Ciências da Saúde da Universidade da Beira Interior (CICS-UBI), 6200-506 Covilhã, Portugal.
- Laboratório de Fármaco-Toxicologia-UBIMedical, Universidade da Beira Interior, 6200-284 Covilhã, Portugal.
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D'Souza G, Wren AA, Almgren C, Ross AC, Marshall A, Golianu B. Pharmacological Strategies for Decreasing Opioid Therapy and Management of Side Effects from Chronic Use. CHILDREN 2018; 5:children5120163. [PMID: 30563157 PMCID: PMC6306833 DOI: 10.3390/children5120163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 11/27/2018] [Accepted: 12/03/2018] [Indexed: 12/04/2022]
Abstract
As awareness increases about the side effects of opioids and risks of misuse, opioid use and appropriate weaning of opioid therapies have become topics of significant clinical relevance among pediatric populations. Critically ill hospitalized neonates, children, and adolescents routinely receive opioids for analgesia and sedation as part of their hospitalization, for both acute and chronic illnesses. Opioids are frequently administered to manage pain symptoms, reduce anxiety and agitation, and diminish physiological stress responses. Opioids are also regularly prescribed to youth with chronic pain. These medications may be prescribed during the initial phase of a diagnostic workup, during an emergency room visit; as an inpatient, or on an outpatient basis. Following treatment for underlying pain conditions, it can be challenging to appropriately wean and discontinue opioid therapies. Weaning opioid therapy requires special expertise and care to avoid symptoms of increased pain, withdrawal, and agitation. To address this challenge, there have been enhanced efforts to implement opioid-reduction during pharmacological therapies for pediatric pain management. Effective pain management therapies and their outcomes in pediatrics are outside the scope of this paper. The aims of this paper were to: (1) Review the current practice of opioid-reduction during pharmacological therapies; and (2) highlight concrete opioid weaning strategies and management of opioid withdrawal.
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Affiliation(s)
- Genevieve D'Souza
- Department of Anesthesia, Perioperative and Pain Medicine, Stanford University, Palo Alto, CA 94304, USA.
| | - Anava A Wren
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Stanford University, Palo Alto, CA 94304, USA.
| | - Christina Almgren
- Department of Anesthesia, Perioperative and Pain Medicine, Stanford University, Palo Alto, CA 94304, USA.
| | - Alexandra C Ross
- Department of Anesthesia, Perioperative and Pain Medicine, Stanford University, Palo Alto, CA 94304, USA.
| | - Amanda Marshall
- Department of Anesthesia, Perioperative and Pain Medicine, Stanford University, Palo Alto, CA 94304, USA.
| | - Brenda Golianu
- Department of Anesthesia, Perioperative and Pain Medicine, Stanford University, Palo Alto, CA 94304, USA.
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Marcellus L. Social Ecological Examination of Factors That Influence the Treatment of Newborns With Neonatal Abstinence Syndrome. J Obstet Gynecol Neonatal Nurs 2018; 47:509-519. [DOI: 10.1016/j.jogn.2018.04.135] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2018] [Indexed: 10/28/2022] Open
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Walsh MC, Crowley M, Wexelblatt S, Ford S, Kuhnell P, Kaplan HC, McClead R, Macaluso M, Lannon C. Ohio Perinatal Quality Collaborative Improves Care of Neonatal Narcotic Abstinence Syndrome. Pediatrics 2018. [PMID: 29514974 DOI: 10.1542/peds.2017-0900] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Neonatal abstinence syndrome (NAS) after an infant's in-utero exposure to opioids has increased dramatically in incidence. No treatment standards exist, leading to substantial variations in practice, degree of opioid exposure, and hospital length of stay. METHODS The Ohio Perinatal Quality Collaborative conducted an extensive multi-modal quality improvement initiative with the goal to (1) standardize identification, nonpharmacologic and pharmacologic treatment in level-2 and 3 NICUs in Ohio, (2) reduce the use of and length of treatment with opioids, and (3) reduce hospital length of stay in pharmacologically treated newborns with NAS. RESULTS Fifty-two of 54 (96%) Ohio NICUs participated in the collaborative. Compliance with the nonpharmacologic bundle improved from 37% to 59%, and the pharmacologic bundle improved from 59% to 68%. Forty-eight percent of the 3266 opioid-exposed infants received pharmacologic treatment of symptoms of NAS, and this rate did not change significantly across the time period. Regardless of the opioid used to pharmacologically treat infants with NAS, the length of treatment decreased from 13.4 to 12.0 days, and length of stay decreased from 18.3 to 17 days. CONCLUSIONS Standardized approaches to the identification and nonpharmacologic and pharmacologic care were associated with a reduced length of opioid exposure and hospital stay in a large statewide collaborative. Other states and institutions treating opioid-exposed infants may benefit from the adoption of these practices.
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Affiliation(s)
- Michele C Walsh
- Division of Neonatology and Department of Pediatrics, Rainbow Babies & Children's Hospital, Cleveland, Ohio; .,Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
| | - Moira Crowley
- Division of Neonatology and Department of Pediatrics, Rainbow Babies & Children's Hospital, Cleveland, Ohio.,Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
| | - Scott Wexelblatt
- Anderson Center for Health Systems Excellence and.,Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Susan Ford
- Division of Neonatology and Department of Pediatrics, Rainbow Babies & Children's Hospital, Cleveland, Ohio
| | - Pierce Kuhnell
- Division of Biostatistics and Epidemiology, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Heather C Kaplan
- Anderson Center for Health Systems Excellence and.,Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Richard McClead
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio; and.,Department of Pediatrics, Ohio State University, Columbus, Ohio
| | - Maurizio Macaluso
- Anderson Center for Health Systems Excellence and.,Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Carole Lannon
- Anderson Center for Health Systems Excellence and.,Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
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Abstract
BACKGROUND As opioid abuse increases in the United States, the rate of neonatal abstinence syndrome (NAS) rises dramatically. Caring for infants with NAS and their families is a significant challenge to neonatal nurses. PURPOSE The purpose of this survey study was to explore attitudes and practice trends among nurses caring for infants with NAS. The study also aimed to identify any gaps in knowledge about NAS. METHOD An anonymous, cross-sectional survey study was conducted using a researcher-developed questionnaire. The survey questionnaire included 20 Likert-scale questions regarding nurses' attitudes, knowledge, and practice in care of infants with NAS, 1 case study with 3 questions, and 2 open-ended questions. Nurses, including advanced practice nurses and nurse leaders, were invited to participate at a regional neonatal nursing conference in the New England area. RESULTS A total of 54 participants responded, the majority being white, female, non-Hispanic, and bachelor's prepared. Many nurses shared concerns regarding the setting in which infants with NAS are cared for. Nurses expressed varying attitudes regarding interacting with the mothers but generally wanted to build a partnership with them. Nurses also reported a lack of standardized and consistent practice in care for infants with NAS. Three major themes were identified from open-ended questions, including environmental issues, relationship with the mother, and inconsistency in care. IMPLICATIONS FOR PRACTICE Further research is needed for nurses providing care to infants with NAS. Specific education programs are needed for nurses who are caring for infants with NAS. IMPLICATIONS FOR RESEARCH Further research is needed regarding the effects of NAS on nurses and other healthcare providers.
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Gomez-Pomar E, Finnegan LP. The Epidemic of Neonatal Abstinence Syndrome, Historical References of Its' Origins, Assessment, and Management. Front Pediatr 2018; 6:33. [PMID: 29520355 PMCID: PMC5827164 DOI: 10.3389/fped.2018.00033] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 02/05/2018] [Indexed: 11/13/2022] Open
Abstract
Neonatal abstinence syndrome (NAS) refers to a constellation of signs that are present in some newborn infants resulting from the abrupt cessation of passive transfer of maternal opioids used during pregnancy. The classic NAS refers to infants born to mothers who used opioids during pregnancy, but the term has broadened to include infants whose mothers have used or abused other psychoactive substances during pregnancy that contribute to the expression of the syndrome. Pregnant women who use opioids do so illicitly, and/or as medically prescribed for pain relief, and/or as medication assisted treatment for opioid dependence. The first case of NAS in infants and the subsequent treatment (or lack thereof) was reported in 1875 and was called Congenital Morphinism. By 2012, the incidence of NAS increased to more than 30 per 1,000 hospital live births, along with an increase in the number of infants being treated pharmacologically for NAS, resulting in an increase in the length of stay and healthcare expenses. We present historical references on NAS, the various factors and events that led to its increasing prevalence and today's current epidemic. We also review the current tools to assess infants with NAS and treatment options in its management.
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Affiliation(s)
- Enrique Gomez-Pomar
- Division of Neonatology, Department of Pediatrics, University of Kentucky, Lexington, KY, United States
| | - Loretta P. Finnegan
- The College on Problems of Drug Dependence, Inc., Philadelphia, PA, United States
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A Quality Improvement Initiative to Increase Scoring Consistency and Accuracy of the Finnegan Tool: Challenges in Obtaining Reliable Assessments of Drug Withdrawal in Neonatal Abstinence Syndrome. Adv Neonatal Care 2018; 18:70-78. [PMID: 29045256 DOI: 10.1097/anc.0000000000000441] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Current practice for diagnosing neonatal abstinence syndrome and guiding pharmacological management of neonatal drug withdrawal is dependent on nursing assessments and repeated evaluation of clinical signs. PURPOSE This single-center quality improvement initiative was designed to improve accuracy and consistency of Finnegan scores among neonatal nurses. METHODS One-hundred seventy neonatal nurses participated in a single-session withdrawal-assessment program that incorporated education, scoring guidelines, and a restructured Finnegan scale. Nurses scored a standardized video-recorded infant presenting with opioid withdrawal before and after training. RESULTS Nearly twice as many nurses scored at target (Finnegan score of 8) posttraining (34.7%; mean error = 0.559, SD = 1.4) compared with pretraining (18.8%; mean error = 1.31, SD = 1.95; Wilcoxon, P < .001). Finnegan scores were significantly higher than the target score pretraining (mean = 9.31, SD = 1.95) compared with posttraining (mean = 8.56, SD = 1.40, Wilcoxon P < .001); follow-up assessments reverted to pretraining levels (mean = 9.16, SD = 1.8). Score dispersion was greater pretraining (variance 3.80) compared with posttraining (variance 1.96; Kendall's Coefficient, P < .001) largely due to score disparity among central nervous system symptomology. IMPLICATIONS FOR PRACTICE Education, clinical guidelines, and a restructured scoring tool increased consistency and accuracy of infant withdrawal-assessments among neonatal nurses. However, more than 60% of nurses did not assess withdrawal to the target score immediately following the training period and improvements did not persist over time. IMPLICATIONS FOR RESEARCH This study highlights the need for more objective tools to quantify withdrawal severity given that assessments are the primary driver of pharmacological management in neonatal drug withdrawal.Video Abstract available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx.
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Cohen‐Israel M, Berger I, Martonovich EY, Klinger G, Stahl B, Linder N. Short- and long-term complications of in utero exposure to lamotrigine. Br J Clin Pharmacol 2018; 84:189-194. [PMID: 29044597 PMCID: PMC5736833 DOI: 10.1111/bcp.13437] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 08/16/2017] [Accepted: 08/30/2017] [Indexed: 12/01/2022] Open
Abstract
AIMS The present study evaluates the effect of antenatal lamotrigine exposure, on short- and long-term paediatric outcome. METHODS The study included the children of 83 epileptic women treated with lamotrigine during pregnancy, at a tertiary medical centre between 2004-2014. All newborns were monitored for vital signs, congenital malformations and Finnegan score. In addition, the parents completed a questionnaire regarding their child's development and health up to the age of 12 years. RESULTS No major malformations were found in the newborns. None of the newborns had significant withdrawal symptoms by Finnegan score. The children were followed-up to the age of 12 years (56.6% were 6-12 years at the time of evaluation). There were no significant findings in the incidence of neurodevelopmental disorders. CONCLUSIONS According to our experience, lamotrigine is generally safe for pregnancy use, associated with minimal short-term complications with no long-term effects on the outcome.
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Affiliation(s)
- Merav Cohen‐Israel
- Department of PediatricsSchneider Children's Medical Center of IsraelPetach TikvaIsrael
| | - Itai Berger
- Pediatric Neurology UnitHadassah‐Hebrew University Medical CenterJerusalemIsrael
| | - Einat Y. Martonovich
- Department of PediatricsSchneider Children's Medical Center of IsraelPetach TikvaIsrael
- Department of NeonatologyRabin Medical Center‐Beilinson HospitalPetach TikvaIsrael
| | - Gil Klinger
- Department of PediatricsSchneider Children's Medical Center of IsraelPetach TikvaIsrael
- Sackler Faculty of MedicineTel Aviv UniversityTel AvivIsrael
| | - Bracha Stahl
- Department of NeonatologyRabin Medical Center‐Beilinson HospitalPetach TikvaIsrael
| | - Nehama Linder
- Department of NeonatologyRabin Medical Center‐Beilinson HospitalPetach TikvaIsrael
- Sackler Faculty of MedicineTel Aviv UniversityTel AvivIsrael
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40
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Galbally M, Spigset O, Johnson AR, Kohan R, Lappas M, Lewis AJ. Neonatal adaptation following intrauterine antidepressant exposure: assessment, drug assay levels, and infant development outcomes. Pediatr Res 2017; 82:806-813. [PMID: 28665925 DOI: 10.1038/pr.2017.156] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 06/20/2017] [Indexed: 01/22/2023]
Abstract
BackgroundAlthough a meta-analysis has confirmed the association between antidepressant exposure in utero and subsequent poor neonatal adaptation, few identified studies included drug levels or standardized measures and only two studies followed up children who developed symptoms beyond infancy.MethodsThe study draws on the Mercy Pregnancy and Emotional Wellbeing Study and reports on 42 women/infant pairs at delivery. In all, 31 women continued to take antidepressants until delivery and 11 ceased earlier in pregnancy. Poor neonatal adaptation was assessed twice daily for up to 6 days by using the Neonatal Abstinence Scoring System (NASS). Drug levels were analyzed in umbilical cord blood and maternal blood obtained at delivery.ResultsIn total, 76% (32 of 42) of neonates exposed to antidepressants had symptoms observed on the NASS. These symptoms occurred up to 5 days postpartum with 25% having symptoms that persisted for more than 3 days. The most frequent symptoms were correlated most closely to antidepressant drug levels. Elevated NASS scores were found to be associated with poorer fine motor development at 6 months of age.ConclusionsPoor neonatal adaptation may be more common than previously recognized. The NASS was observed to be an effective assessment and monitoring measure. Research following symptomatic infants beyond the neonatal period is required.
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Affiliation(s)
- Megan Galbally
- School of Psychology and Exercise Science, Murdoch University, Perth, Western Australia, Australia
| | - Olav Spigset
- Department of Clinical Pharmacology, St Olav University Hospital, Trondheim, Norway
| | - Andrew R Johnson
- School of Psychology and Speech Pathology, Curtin University, Perth, Western Australia, Australia
| | - Rolland Kohan
- School of Women and Infant Health, School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia, Australia
| | - Martha Lappas
- Obstetrics, Nutrition and Endocrinology Group, Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew J Lewis
- School of Psychology and Exercise Science, Murdoch University, Perth, Western Australia, Australia
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Gomez Pomar E, Finnegan LP, Devlin L, Bada H, Concina VA, Ibonia KT, Westgate PM. Simplification of the Finnegan Neonatal Abstinence Scoring System: retrospective study of two institutions in the USA. BMJ Open 2017; 7:e016176. [PMID: 28963285 PMCID: PMC5623549 DOI: 10.1136/bmjopen-2017-016176] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To develop a simplified Finnegan Neonatal Abstinence Scoring System (sFNAS) that will highly correlate with scores ≥8 and ≥12 in infants being assessed with the FNAS. DESIGN, SETTING AND PARTICIPANTS This is a retrospective analysis involving 367 patients admitted to two level IV neonatal intensive care units with a total of 40 294 observations. Inclusion criteria included neonates with gestational age ≥37 0/7 weeks, who are being assessed for neonatal abstinence syndrome (NAS) using the FNAS. Infants with a gestational age <37 weeks were excluded. METHODS A linear regression model based on the original FNAS data from one institution was developed to determine optimal values for each item in the sFNAS. A backward elimination approach was used, removing the items that contributed least to the Pearson's correlation. The sFNAS was then cross-validated with data from a second institution. RESULTS Pearson's correlation between the proposed sFNAS and the FNAS was 0.914. The optimal treatment cut-off values for the sFNAS were 6 and 10 to predict FNAS scores ≥8 and ≥12, respectively. The sensitivity and specificity of these cut-off values to detect FNAS scores ≥8 and ≥12 were 0.888 and 0.883 for a cut-off of 6, and 0.637 and 0.992 for a cut-off of 10, respectively. The sFNAS cross-validation resulted in a Pearson's correlation of 0.908, sensitivity and specificity of 0.860 and 0.873 for a cut-off of 6, and 0.525 and 0.986 for a cut-off of 10, respectively. CONCLUSION The sFNAS has a high statistical correlation with the FNAS, and it is cross-validated for the assessment of infants with NAS. It has excellent specificity and negative predictive value for identifying infants with FNAS scores ≥8 and ≥12.
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Affiliation(s)
- Enrique Gomez Pomar
- Department of Pediatrics, Division of Neonatology, University of Kentucky, Frankfort, Kentucky, USA
| | | | - Lori Devlin
- Department of Pediatrics, Division of Neonatology, University of Louisville, Louisville, Kentucky, USA
| | - Henrietta Bada
- Department of Pediatrics, Division of Neonatology, University of Kentucky, Frankfort, Kentucky, USA
| | - Vanessa A Concina
- Department of Pediatrics, Division of Neonatology, University of Kentucky, Frankfort, Kentucky, USA
| | - Katrina T Ibonia
- Department of Pediatrics, Division of Neonatology, University of Kentucky, Frankfort, Kentucky, USA
| | - Philip M Westgate
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, Kentucky, USA
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Treating Neonatal Abstinence Syndrome from Clinical Perspectives. IRANIAN JOURNAL OF PEDIATRICS 2017. [DOI: 10.5812/ijp.6266] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Pharmacotherapy for Neonatal Abstinence Syndrome: Choosing the Right Opioid or No Opioid at All. Neonatal Netw 2017; 35:314-20. [PMID: 27636696 DOI: 10.1891/0730-0832.35.5.314] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Neonatal abstinence syndrome (NAS) from in utero opioid exposure has reached epidemic levels in the United States. Although nonpharmacologic therapies form the foundation of care, many neonates require pharmacotherapy. Morphine represents the most widely used first-line agent and effectively treats the symptoms of withdrawal. However, methadone or buprenorphine may facilitate earlier discharge. Although phenobarbital is traditionally used when opioids fail, clonidine may be a more appropriate adjunctive agent to minimize negative neurodevelopmental impact. Consideration of the available data allows hospitals to generate effective pharmacologic strategies to manage NAS while further research continues.
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Analysis of the factors that influence the Finnegan Neonatal Abstinence Scoring System. J Perinatol 2017; 37:814-817. [PMID: 28383539 DOI: 10.1038/jp.2017.40] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/28/2017] [Accepted: 03/07/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To evaluate factors that can influence the Finnegan Neonatal Abstinence Score (FNAS). STUDY DESIGN Retrospective analysis of 367 patients admitted to two level IV neonatal intensive care units. Linear mixed effects models were developed to evaluate daily census, time of the day, and day of the week as fixed effect predictors. The degree of influence that nurses had on FNAS variability was also estimated. RESULTS Bivariate analyses showed that daily census and the time of day have significant influence on the FNAS in institution 1, with minimal clinical significance. The proportion of variation in the FNAS attributable to differences in nurses was of 9.8% and 5.1% for institutions 1 and 2, respectively (P<0.0001). CONCLUSIONS The minimal influences of extraneous factors on the FNAS support the clinical utility of the scoring system in the assessment and management of infants with Neonatal Abstinence Score.
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Yang A, Ciolino JD, Pinheiro E, Rasmussen-Torvik LJ, Sit DKY, Wisner KL. Neonatal Discontinuation Syndrome in Serotonergic Antidepressant-Exposed Neonates. J Clin Psychiatry 2017; 78:605-611. [PMID: 28570796 PMCID: PMC7087396 DOI: 10.4088/jcp.16m11044] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 10/20/2016] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To determine whether infants exposed in utero to serotonin reuptake inhibitor (SRI) antidepressants or a DSM-IV-TR-defined mood disorder have significantly more neonatal discontinuation signs compared to an unexposed group of infants at 2-4 weeks after birth. METHODS This secondary analysis was derived from 2 observational studies with enrollment from July 2000 to December 2011 in Cleveland, Ohio, and Pittsburgh, Pennsylvania. Mothers (n = 214) belonged to one of 3 groups based on exposure status during pregnancy: (1) Comparison-women who did not take psychotropics during pregnancy and had no major mood disorder; (2) SRI-exposed-women with a mood disorder who were taking an SRI but no benzodiazepines; and (3) Mood Disorder-women with depression or bipolar disorder who did not take psychotropic medications. The infants were examined for signs according to the Finnegan Scale by evaluators blind to maternal exposure status. RESULTS The rates of sign presence (defined as a score ≥ 2 on the Finnegan Scale) in the SRI, Mood Disorder, and Comparison groups were similar at 34.1%, 35.1%, and 30.4%, respectively. Women in the SRI group had a significantly higher preterm birth rate (24.4%) compared to the other 2 groups (7.4% and 8.9% in the Mood Disorder and Comparison groups, respectively; P = .012). Preterm newborns had a significantly higher sign rate compared to full-term newborns (54% vs 31%, P = .020). We observed a significant relationship between Finnegan signs and preterm birth. CONCLUSIONS The presence of neonatal signs at 2-4 weeks was more closely associated with prematurity than with in utero SRI or mood disorder exposure. TRIAL REGISTRATION ClinicalTrials.gov identifiers: NCT00279370 and NCT00585702.
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Affiliation(s)
- Amy Yang
- Biostatistics Collaboration Center, Department of
Preventive Medicine Feinberg School of Medicine Northwestern University, Chicago,
Illinois
| | - Jody D. Ciolino
- Biostatistics Collaboration Center, Department of
Preventive Medicine Feinberg School of Medicine Northwestern University, Chicago,
Illinois
| | - Emily Pinheiro
- Asher Center for the Study and Treatment of Depressive
Disorders Department of Psychiatry and Behavioral Sciences, Northwestern University,
Chicago, Illinois
| | | | - Dorothy K. Y. Sit
- Department of Psychiatry and Behavioral Science Feinberg
School of Medicine, Northwestern University, Chicago, Illinois
| | - Katherine L. Wisner
- Norman and Helen Asher Professor of Psychiatry and
Behavioral Sciences, and Obstetrics and Gynecology, Asher Center for the Study and
Treatment of Depressive Disorders, Northwestern University Feinberg School of
Medicine, Chicago, Illinois,Corresponding author: Katherine
L. Wisner, MD, Asher Center for the Study and Treatment of Depressive Disorders
Northwestern University Feinberg School of Medicine, 676 North Saint Clair St,
Ste 1000, Chicago, IL 60611
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Westgate PM, Gomez-Pomar E. Judging the Neonatal Abstinence Syndrome Assessment Tools to Guide Future Tool Development: The use of Clinimetrics as Opposed to Psychometrics. Front Pediatr 2017; 5:204. [PMID: 28979894 PMCID: PMC5611403 DOI: 10.3389/fped.2017.00204] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 09/06/2017] [Indexed: 01/09/2023] Open
Abstract
In the face of the current Neonatal Abstinence Syndrome (NAS) epidemic, there is considerable variability in the assessment and management of infants with NAS. In this manuscript, we particularly focus on NAS assessment, with special attention given to the popular Finnegan Neonatal Abstinence Score (FNAS). A major instigator of the problem of variable practices is that multiple modified versions of the FNAS exist and continue to be proposed, including shortened versions. Furthermore, the validity of such assessment tools has been questioned, and as a result, the need for better tools has been suggested. The ultimate purpose of this manuscript, therefore, is to increase researchers' and clinicians' understanding on how to judge the usefulness of NAS assessment tools in order to guide future tool development and to reduce variable practices. In short, we suggest that judgment of NAS assessment tools should be made on a clinimetrics viewpoint as opposed to psychometrically. We provide examples, address multiple issues that must be considered, and discuss future tool development. Furthermore, we urge researchers and clinicians to come together, utilizing their knowledge and experience, to assess the utility and practicality of existing assessment tools and to determine if one or more new or modified tools are needed with the goal of increased agreement on the assessment of NAS in practice.
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Affiliation(s)
- Philip M Westgate
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, KY, United States
| | - Enrique Gomez-Pomar
- Division of Neonatology, Department of Pediatrics, University of Kentucky, Lexington, KY, United States
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Arrowood GL. Inside the Eyes of a Mother With Addiction. Nurs Womens Health 2016; 20:522-524. [PMID: 27719782 DOI: 10.1016/j.nwh.2016.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Indexed: 10/20/2022]
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Satar M, Ortaköylü K, Batun İ, Yıldızdaş HY, Özlü F, Demir H, Topaloğlu AK. Withdrawal syndrome and hypomagnesaemia and in a newborn exposed to valproic acid and carbamazepine during pregnancy. TURK PEDIATRI ARSIVI 2016; 51:114-116. [PMID: 27489470 PMCID: PMC4959740 DOI: 10.5152/turkpediatriars.2016.3142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 12/28/2015] [Indexed: 06/06/2023]
Abstract
The usage of drugs during pregnancy affect the fetus and the newborn. In this report, we present findings from a newborn baby, whose mother was epileptic, and was under the treatment of valproic acid and carbamazepine during pregnancy. We have found symptoms of withdrawal syndrome, hyponatremia and feeding problem, which was most probably related to exposure to the mentioned drugs. We have also diagnosed hypomagnesaemia and atrial septal defect 4 milimeters in diameter. There are already many reports about the side effects of valproic acid and carbamazepine usage during pregnancy. To the best of our knowledge, hypomagnesaemia has not yet been reported as a side effect. We think that hypomagnesaemia is also related to the usage of antiepileptics.
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Affiliation(s)
- Mehmet Satar
- Division of Neonatology, Department of Pediatrics, Çukurova University School of Medicine, Adana, Turkey
| | - Kadir Ortaköylü
- Department of Pediatrics, Çukurova University School of Medicine, Adana, Turkey
| | - İnci Batun
- Department of Pediatrics, Çukurova University School of Medicine, Adana, Turkey
| | - Hacer Y. Yıldızdaş
- Division of Neonatology, Department of Pediatrics, Çukurova University School of Medicine, Adana, Turkey
| | - Ferda Özlü
- Division of Neonatology, Department of Pediatrics, Çukurova University School of Medicine, Adana, Turkey
| | - Hüsnü Demir
- Division of Pediatric Cardiology, Department of Pediatrics, Çukurova University School of Medicine, Adana, Turkey
| | - Ali Kemal Topaloğlu
- Division of Pediatric Endocrinology, Department of Pediatrics, Çukurova University School of Medicine, Adana, Turkey
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Abstract
Opioid use in pregnancy has increased dramatically over the past decade. Since prenatal opioid use is associated with numerous obstetrical and neonatal complications, this now has become a major public health problem. In particular, in utero opioid exposure can result in neonatal abstinence syndrome (NAS) which is a serious condition characterized by central nervous system hyperirritability and autonomic nervous system dysfunction. The present review seeks to define current practices regarding the approach to the pregnant mother and neonate with prenatal opiate exposure. Although the cornerstone of prenatal management of opioid dependence is opioid maintenance therapy, the ideal agent has yet to be definitively established. Pharmacologic management of NAS is also highly variable and may include an opioid, barbiturate, and/or α-agonist. Genetic factors appear to be associated with the incidence and severity of NAS. Establishing pharmacogenetic risk factors for the development of NAS has the potential for creating opportunities for "personalized genomic medicine" and novel, individualized therapeutic interventions.
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Patterns of Disruptive Feeding Behaviors in Infants With Neonatal Abstinence Syndrome. Adv Neonatal Care 2015; 15:429-39; quiz E1-2. [PMID: 26308605 DOI: 10.1097/anc.0000000000000204] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Severe irritability in infants with neonatal abstinence syndrome often impacts their ability to feed successfully, which challenges a mother's ability to demonstrate this most basic parenting skill. There is little empiric evidence to guide recommendations for practice in this population. PURPOSE Describe the infant behaviors that disrupt feeding in infants with neonatal abstinence syndrome. METHODS A mixed-method approach was used to describe digitally recorded infant feeding behaviors. Qualitative methodology was first used to identify categories of behaviors during the feeding. The categories were used as a coding scheme to identify the temporal sequence, duration, and frequency of behaviors observed during a feeding. RESULTS The behavior categories that disrupted feeding were identified as fussing, resting, crying, and sleeping/sedated. Infants spent almost twice as much time in fussing as in feeding. The majority of the infants were fussing between 1 and 11 minutes during the feeding, and fussing disrupted feeding in every subject at least once. Feeding behavior occurred only 24% of the time, while fussing and crying occurred 51%. Fussing was the primary transitional behavior from one category to another. Infants who did not complete their feeding had nearly twice the mean number of fussing episodes as those who completed their feeding. IMPLICATIONS FOR PRACTICE Fussing is a transitional state and appears to provide an opportunity to test interventions that help the mothers re-engage their infants in feeding. The frequency of the behavioral transitions provides a measure of irritability that has not been previously described in this population. IMPLICATIONS FOR RESEARCH Additional study is needed to evaluate the impact and contributions of maternal behaviors and external variables on infant behavioral transition.
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