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Ganske IM, Langa OC, Cappitelli AT, Nuzzi LC, Staffa SJ, DiTullio N, Fullerton Z, Alrayashi W, Meara JG, Rogers-Vizena CR. Perioperative Pain Management After Primary Palate Repair: A 3-Surgeon Retrospective Study. Cleft Palate Craniofac J 2022; 60:577-585. [PMID: 35648409 DOI: 10.1177/10556656221075932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Pain management strategies following palatoplasty vary substantially. Despite efforts to reduce narcotic utilization, specific analgesic regimens are typically guided by surgeon preference. Our aim was to define analgesic variables that affect postoperative narcotic use and time to resumption of oral intake. DESIGN This is a retrospective review from 2015 to 2018. PATIENTS Nonsyndromic patients undergoing primary palate repair. MAIN OUTCOMES MEASURES Analgesic variables included: local anesthetic, pterygopalatine ganglion nerve block, palatal pack, and postoperative use of ketorolac, dexamethasone, and nursing-controlled analgesia (NCA) opioid dosing. Proxy measures for pain included time to resumption of oral intake and morphine equivalence (mg/kg/h) administered. RESULTS Veau phenotypes for the 111 patients included were: I (28%), II (19%), III (33%), IV (16%), and submucous (4%). Age, weight, local anesthetic, and postoperative use of ketorolac, dexamethasone, and palatal pack had no effect on either proxy measure (P > .05). Postoperative narcotic usage was significantly lower in patients who had an intraoperative suprazygomatic peripheral nerve block and significantly higher when NCA was utilized (P < .05). Neither variable had a significant impact on time to resumption of oral intake (P > .05). CONCLUSION Several perioperative analgesic strategies lead to comparable postoperative consumption of narcotic and time to resume oral intake. The authors advise careful consideration of NCA due to the potential for increased narcotic utilization that we found in our institution. Based on our promising findings, further studies are warranted to assess risks, benefits, and costs of performing peripheral nerve blocks at the time of palatoplasty.
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Affiliation(s)
- Ingrid M Ganske
- Department of Plastic and Oral Surgery, 1862Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Olivia C Langa
- Department of Plastic and Oral Surgery, 1862Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Alex T Cappitelli
- Department of Plastic and Oral Surgery, 1862Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Laura C Nuzzi
- Department of Plastic and Oral Surgery, 1862Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Steven J Staffa
- Department of Plastic and Oral Surgery, 1862Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Nancy DiTullio
- Department of Plastic and Oral Surgery, 1862Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Zoe Fullerton
- Department of Plastic and Oral Surgery, 1862Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Walid Alrayashi
- Department of Anesthesiology, Critical Care and Pain Medicine, 1862Boston Children's Hospital and Harvard Medical School, Boston MA, USA
| | - John G Meara
- Department of Plastic and Oral Surgery, 1862Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Carolyn R Rogers-Vizena
- Department of Plastic and Oral Surgery, 1862Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
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Mahnke AH, Roberts MH, Leeman L, Ma X, Bakhireva LN, Miranda RC. Prenatal opioid-exposed infant extracellular miRNA signature obtained at birth predicts severity of neonatal opioid withdrawal syndrome. Sci Rep 2022; 12:5941. [PMID: 35396369 PMCID: PMC8993911 DOI: 10.1038/s41598-022-09793-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 03/29/2022] [Indexed: 11/09/2022] Open
Abstract
Prenatal opioid exposure (POE) is commonly associated with neonatal opioid withdrawal syndrome (NOWS), which is characterized by a broad variability in symptoms and severity. Currently there are no diagnostic tools to reliably predict which infants will develop severe NOWS, while risk stratification would allow for proactive decisions about appropriate clinical monitoring and interventions. The aim of this prospective cohort study was to assess if extracellular microRNAs (miRNAs) in umbilical cord plasma of infants with POE could predict NOWS severity. Participants (n = 58) consisted of pregnant women receiving medications for opioid use disorder and their infants. NOWS severity was operationalized as the need for pharmacologic treatment and prolonged hospitalization (≥ 14 days). Cord blood miRNAs were assessed using semi-quantitative qRT-PCR arrays. Receiver operating characteristic curves and area under the curve (AUC) were estimated. The expression of three miRNAs (miR-128-3p, miR-30c-5p, miR-421) predicted need for pharmacologic treatment (AUC: 0.85) and prolonged hospitalization (AUC: 0.90). Predictive validity improved after two miRNAs (let-7d-5p, miR-584-5p) were added to the need for pharmacologic treatment model (AUC: 0.94) and another two miRNAs (let-7b-5p, miR-10-5p) to the prolonged hospitalization model (AUC: 0.99). Infant cord blood extracellular miRNAs can proactively identify opioid-exposed neonates at high-risk for developing severe NOWS.
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Affiliation(s)
- Amanda H Mahnke
- Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M University Health Science Center, 8447 Riverside Parkway, Bryan, TX, 77807-3260, USA.
| | - Melissa H Roberts
- Department of Pharmacy Practice and Administrative Sciences, Substance Use Research and Education (SURE) Center, University of New Mexico College of Pharmacy, Albuquerque, NM, 87131, USA
| | - Lawrence Leeman
- Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque, NM, 87106, USA.,Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque, NM, 87106, USA
| | - Xingya Ma
- Department of Pharmacy Practice and Administrative Sciences, Substance Use Research and Education (SURE) Center, University of New Mexico College of Pharmacy, Albuquerque, NM, 87131, USA
| | - Ludmila N Bakhireva
- Department of Pharmacy Practice and Administrative Sciences, Substance Use Research and Education (SURE) Center, University of New Mexico College of Pharmacy, Albuquerque, NM, 87131, USA.,Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque, NM, 87106, USA.,Division of Epidemiology, Biostatistics and Preventive Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, 87106, USA
| | - Rajesh C Miranda
- Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M University Health Science Center, 8447 Riverside Parkway, Bryan, TX, 77807-3260, USA
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Singleton R, Slaunwhite A, Herrick M, Hirschfeld M, Brunner L, Hallas C, Truit S, Hanson S, Young M, Rider E. Research and policy priorities for addressing prenatal exposure to opioids in Alaska. Int J Circumpolar Health 2019; 78:1599275. [PMID: 31020919 PMCID: PMC6493296 DOI: 10.1080/22423982.2019.1599275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 02/24/2019] [Accepted: 03/15/2019] [Indexed: 12/18/2022] Open
Abstract
The current opioid crisis in Alaska and the USA will negatively affect the health and wellbeing of future generations. The increasing number of infants born with neonatal opioid withdrawal syndrome (NOWS) has had a profound impact on families, health care providers and the child welfare system. This manuscript summarises the main themes of a Symposium held in Anchorage, Alaska with health care providers, researchers, elders and public health officials that focused on identifying emerging challenges, trends and potential solutions to address the increasing number of infants and children affected by maternal opioid use. Five areas of importance for research and policy development that would direct improvement in the care of infants with NOWS in Alaska are outlined with the goal of supporting a research agenda on opioid misuse and child health across the circumpolar north. Abbreviations: NOWS - neonatal opioid withdrawal syndrome; NAS - neonatal abstinence syndrome; MAT - medication-assisted treatment; NICU - neonatal intensive care unit; OATs - opioid agonist treatments; OCS - office of children's services; ANTHC - Alaska Native Tribal Health Consortium; OUD - opioid use disorder; SBIRT - screening, brief intervention and referral to treatment; ISPCTN - IDeA States Pediatric Clinical Trials Network; NIH - National Institutes of Health; ANMC - Alaska Native Medical Center; DHSS - Department of Health and Social Services; AAPP - All Alaska Pediatric Partnership.
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Affiliation(s)
| | | | | | | | | | - Christine Hallas
- Alaska Native Tribal Health Consortium, Anchorage, AK, USA
- Southcentral Foundation, Anchorage, AK, USA
| | | | | | - Margaret Young
- Division of Public Health, Department of Health and Social Services, State of Alaska, Anchorage, AK, USA
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Abstract
Tens of thousands of infants are impacted yearly by prenatal opioid exposure. The term neonatal opioid withdrawal syndrome (NOWS) is now replacing the more familiar term neonatal abstinence syndrome (NAS). Ongoing debate continues related to standard regimens for treatment of this oftentimes perplexing condition. Historically, treatment has focused on pharmacologic interventions. However, there is limited research that points to nonpharmacologic methods of treatment as viable options, whether alone or in addition to pharmacologic interventions. This article, utilizing a review of pertinent literature, outlines the physical aspects of NOWS, including its pathophysiology and the resulting physical clinical signs. In addition, we present an overview of how age-appropriate, nonpharmacologic interventions, centered on developmental care, may be a valuable approach to organize and prioritize routine care for these infants, their families, and the health care team facing the challenges of NOWS. Finally, the need for further research to better define evidence-based standards of care for these infants and their families is discussed.
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5
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Mian P, Tibboel D, Wildschut ED, van den Anker JN, Allegaert K. Morphine treatment for neonatal abstinence syndrome: huge dosing variability underscores the need for a better clinical study design. Minerva Pediatr 2019; 71:263-286. [DOI: 10.23736/s0026-4946.17.04928-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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8
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Jacobs AA, Cangiano M. Medication-Assisted Treatment Considerations for Women with Opiate Addiction Disorders. Prim Care 2018; 45:731-742. [DOI: 10.1016/j.pop.2018.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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10
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Uebel H, Wright IM, Burns L, Hilder L, Bajuk B, Breen C, Abdel-Latif ME, Ward M, Eastwood J, Feller JM, Falconer J, Clews S, Oei JL. Epidemiological Evidence for a Decreasing Incidence of Neonatal Abstinence Syndrome, 2000-11. Paediatr Perinat Epidemiol 2016; 30:267-73. [PMID: 26849178 DOI: 10.1111/ppe.12282] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study analyses the incidence of Neonatal Abstinence Syndrome (NAS) in a large geographically defined population in Australia. METHOD Database linkage analysis of all births between 2000 and 2011 in New South Wales (NSW), Australia. The diagnosis of NAS was derived from hospital coding P96.1, 'Neonatal withdrawal symptoms from maternal use of drugs of addiction'. Temporal trends were studied by comparing epoch 1 (2000-05) with epoch 2 (2006-11). The relationship with changes in maternal factors was further analysed. RESULTS The NAS was coded in 3842 of 1 022 263 live born infants (0.38%). NAS incidence peaked at 5.07 per 1000 live births in 2002, decreasing to 3.18 in 2011 and was negatively correlated with maternal age (r = -0.7). The rate of NAS in epoch 2 (3.4 per 1000 births, 95% CI 3.28, 3.58) was significantly lower than in epoch 1 (4.1 per 1000 births, 95% CI 3.96, 4.33). Epoch 2 mothers were significantly older (mean 29.8 years vs. 28.3 years), less likely to be multiparous (OR 0.7, 95% CI 0.6, 0.9) or smoke (OR 0.4, 95% CI 0.4, 0.5). They were more likely to engage in antenatal care earlier (mean first visit: 14.1 vs. 18.9 weeks). Most infants (~80%) were born at term (>37 weeks gestation). CONCLUSION The incidence of NAS as a discharge diagnosis has decreased in our population since 2002. Mothers are also older and engaging earlier in prenatal care. Whether these changes alter NAS presentation and diagnosis or whether pregnant women are using drugs that do not cause typical NAS (e.g. amphetamines) is uncertain and requires further study.
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Affiliation(s)
- Hannah Uebel
- School of Women's and Children's Heath, University of New South Wales, Kensington, NSW, Australia
| | - Ian M Wright
- Illawarra Health and Medical Research Institute and Graduate School of Medicine, The University of Wollongong, Wollongong, NSW, Australia.,Department of Paediatrics, The Wollongong Hospital, Wollongong, NSW, Australia
| | - Lucy Burns
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Lisa Hilder
- School of Women's and Children's Heath, University of New South Wales, Kensington, NSW, Australia.,Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - Barbara Bajuk
- Perinatal Services Network, Westmead, NSW, Australia
| | - Courtney Breen
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Mohamed E Abdel-Latif
- Department of Neonatology, The Canberra Hospital, Garran, ACT, Australia.,Faculty of Medicine, the Australian National University, Deakin, ACT, Australia
| | - Meredith Ward
- School of Women's and Children's Heath, University of New South Wales, Kensington, NSW, Australia.,Department of Newborn Care, Royal Hospital for Women, Randwick, NSW, Australia
| | - John Eastwood
- School of Women's and Children's Heath, University of New South Wales, Kensington, NSW, Australia.,Sydney Local Health District, Sydney, NSW, Australia.,Ingham Institute of Applied Medicine, University of New South Wales, Liverpool, NSW, Australia
| | - John M Feller
- School of Women's and Children's Heath, University of New South Wales, Kensington, NSW, Australia.,Sydney Children's Hospital, Randwick, NSW, Australia
| | | | - Sara Clews
- The Langton Centre, Surry Hills, NSW, Australia
| | - Ju Lee Oei
- School of Women's and Children's Heath, University of New South Wales, Kensington, NSW, Australia.,Department of Newborn Care, Royal Hospital for Women, Randwick, NSW, Australia.,Ingham Institute of Applied Medicine, University of New South Wales, Liverpool, NSW, Australia
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11
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Whitham JN, Spurrier NJ, Baghurst PA, Weston P, Sawyer MG. Visual evoked potential latencies of three-year-old children prenatally exposed to buprenorphine or methadone compared with non-opioid exposed children: The results of a longitudinal study. Neurotoxicol Teratol 2015; 52:17-24. [PMID: 26432025 DOI: 10.1016/j.ntt.2015.09.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 09/27/2015] [Accepted: 09/28/2015] [Indexed: 10/23/2022]
Abstract
This study compared the latency of pattern reversal visual evoked potentials (VEP) of 36-month old children exposed to opioid pharmacotherapy in utero to that of a group of non-exposed children. Pregnant women were enrolled as part of an open-label non-randomised flexible dosing longitudinal study. Participants were 21 children whose mothers were treated with buprenorphine- (n=11) or methadone-pharmacotherapy (n=10) during pregnancy, and 15 children not exposed to opioids in pregnancy. One-way between groups analyses of variance (ANOVA) were conducted to test the statistical significance of differences between the mean latencies of the peak response to two different sized checkerboard patterns (48' and 69' of retinal arc). Standard multiple regression analyses were conducted to determine whether there was a significant relationship between group status and VEP latencies after adjusting for the effect of covariates. VEP latencies ranged from 98 to 112 milliseconds (ms) for checks of 48' arc, and from 95 to 113ms for checks of 69' arc. Latencies were comparable across groups. After adjusting for covariates children prenatally exposed to methadone or buprenorphine did not differ significantly from non-opioid exposed children in their responses to either check size. Nor were there any significant differences in VEP latencies between children prenatally exposed to methadone and children prenatally exposed to buprenorphine. Head circumference (HC) was significantly associated with P100 latencies for both check sizes. Data from this controlled, non-randomised study suggest that neither buprenorphine nor methadone appear to have any long-term effects on visual maturity assessed at 36months of age.
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Affiliation(s)
- Justine N Whitham
- Discipline of Paediatrics, School of Paediatrics and Reproductive Health, The University of Adelaide, South Australia 5005, Australia; Research and Evaluation Unit, Women's and Children's Health Network, 72 King William Rd, North Adelaide, South Australia 5006, Australia.
| | - Nicola J Spurrier
- Department of Paediatrics and Child Health, Flinders University, Bedford Park, South Australia 5042, Australia; Public Health Partnership Branch, Department for Health and Ageing, SA Health, Citicentre 11 Hindmarsh Square, Adelaide 5000, South Australia, Australia.
| | - Peter A Baghurst
- Public Health Research Unit, Women's and Children's Health Network, 72 King William Rd, North Adelaide, South Australia 5006, Australia.
| | - Paul Weston
- Department of Neurology, Women's and Children's Hospital, 72 King William Rd, North Adelaide, South Australia 5006, Australia.
| | - Michael G Sawyer
- Research and Evaluation Unit, Women's and Children's Health Network, 72 King William Rd, North Adelaide, South Australia 5006, Australia.
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13
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Krans EE, Cochran G, Bogen DL. Caring for Opioid-dependent Pregnant Women: Prenatal and Postpartum Care Considerations. Clin Obstet Gynecol 2015; 58:370-9. [PMID: 25775440 PMCID: PMC4607033 DOI: 10.1097/grf.0000000000000098] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Pregnancy is an opportune time to identify opioid dependence, facilitate conversion to opioid maintenance treatment, and coordinate care with specialists in addiction medicine, behavioral health, and social services. Comprehensive prenatal care for opioid-dependent women involves the evaluation and the management of co-occurring psychiatric disorders, polysubstance use, infectious diseases, social stressors, and counseling regarding the importance of breastfeeding, contraception, and neonatal abstinence syndrome. Although the complex psychiatric, social, and environmental factors faced by this population pose significant challenges to obstetric care providers, the development of strong patient-provider relationships can facilitate the ability to deliver efficient and effective health care during pregnancy.
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Affiliation(s)
- Elizabeth E Krans
- Departments of *Obstetrics, Gynecology & Reproductive Sciences, Magee-Womens Research Institute ‡Pediatrics †School of Social Work, University of Pittsburgh, Pittsburgh, Pennsylvania
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O'Connor A, Lewis L, McLaurin R, Barnett L. Maternal and neonatal outcomes of Hepatitis C positive women attending a midwifery led drug and alcohol service: A West Australian perspective. Midwifery 2015; 31:793-7. [PMID: 25957760 DOI: 10.1016/j.midw.2015.04.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 04/09/2015] [Accepted: 04/11/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND the Women and Newborn Drug and Alcohol Service (WANDAS) is a specialist, midwifery-led service providing pregnancy care to women dealing with alcohol and other drug (AOD) use, at the sole tertiary maternity hospital in Western Australia. AIM to assess the antenatal, intrapartum and neonatal outcomes of women with Hepatitis C (HCV) who attended the WANDAS service between 2009 and 2012. DESIGN this retrospective cohort study used data obtained from computerised midwifery records. Univariate comparisons between those who were HCV positive and those who were not, were performed. Multivariable logistic regression was utilised to investigate the simultaneous factors associated with being HCV positive and an opiate user. FINDINGS the incidence of HCV in this cohort was 37% (213 of 570). Compared to those who were HCV negative those who were positive were more likely to: be older (P<0.001); use opioids in pregnancy (P<0.001); be an intravenous drug user (P<0.001); engage in polysubstance use (P<0.001); and receive an induction of labour (P=0.036). There were no intrapartum characteristics found to be significant at a multivariate level associated with being HCV positive and an opiate user, but there were a couple of neonatal complications. These were having a baby admitted to Special Care Nursery (OR 1.95, 95% CI 1.33-2.88, P<0.001) and a baby at increased risk of being diagnosed with neonatal abstinence syndrome (OR 3.40, 95% CI 2.24-5.15, P<0.001). CONCLUSION our findings highlight the complexity of caring for pregnant women who are HCV positive, they also highlight that all pregnant women who are AOD users are an at risk population. IMPLICATIONS FOR PRACTICE these results improve our understanding of the obstetric and midwifery issues associated with caring for pregnant women who are HCV positive and the value of provision of specialist care from a multidisciplinary team, led by a consultant midwife.
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Affiliation(s)
- Angela O'Connor
- King Edward Memorial Hospital, Subiaco, Western Australia, Australia. angela.o'
| | - Lucy Lewis
- School of Nursing and Midwifery, Curtin University, Western Australia, Australia; Department of Nursing and Midwifery Education and Research, King Edward Memorial Hospital, Subiaco, Western Australia, Australia.
| | - Renate McLaurin
- King Edward Memorial Hospital, Subiaco, Western Australia, Australia.
| | - Lisa Barnett
- King Edward Memorial Hospital, Subiaco, Western Australia, Australia.
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Abstract
Neonatal opioid withdrawal syndrome is common due to the current opioid addiction epidemic. Infants born to women covertly abusing prescription opioids may not be identified as at risk until withdrawal signs present. Buprenorphine is a newer treatment for maternal opioid addiction and appears to result in a milder withdrawal syndrome than methadone. Initial treatment is with nonpharmacological measures including decreasing stimuli, however pharmacological treatment is commonly required. Opioid monotherapy is preferred, with phenobarbital or clonidine uncommonly needed as adjunctive therapy. Rooming-in and breastfeeding may decease the severity of withdrawal. Limited evidence is available regarding long-term effects of perinatal opioid exposure.
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Evidence-based nurse-driven interventions for the care of newborns with neonatal abstinence syndrome. Adv Neonatal Care 2014; 14:376-80. [PMID: 25068529 DOI: 10.1097/anc.0000000000000118] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Neonatal abstinence syndrome (NAS) is a growing problem in the United States, related to increased maternal substance use and abuse, and a set of drug withdrawal symptoms that can affect the central nervous system and gastrointestinal and respiratory systems in the newborn when separated from the placenta at birth. Infants with NAS often require a significant length of stay in the neonatal intensive care unit (NICU). Pharmacologic treatments and physician-directed interventions are well researched, but nursing-specific interventions and recommendations are lacking. A thorough review and analysis of the literature and interviews with neonatal experts guided the development of a nursing clinical practice guideline for infants with NAS in a level IV NICU. Recommended nursing-specific interventions include methods for maternal drug-use identification, initiation and timing of the Finnegan Scoring System to monitor withdrawal symptoms, and bedside interventions to lessen the drug-withdrawal symptoms in the newborn with NAS.
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17
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Abstract
Neonatal abstinence syndrome (NAS) is a result of the sudden discontinuation of fetal exposure to substances that were used or abused by the mother during pregnancy. Withdrawal from licit or illicit substances is becoming more common among neonates in both developed and developing countries. NAS continues to be an important clinical entity throughout much of the world. NAS leads to a constellation of signs and symptoms involving multiple systems. The pathophysiology of NAS is not completely understood. Urine or meconium confirmation may assist the diagnosis and management of NAS. The Finnegan scoring system is commonly used to assess the severity of NAS; scoring can be helpful for initiating, monitoring, and terminating treatment in neonates. Nonpharmacological care is the initial treatment option, and pharmacological treatment is required if an improvement is not observed after nonpharmacological measures or if the infant develops severe withdrawal. Morphine is the most commonly used drug in the treatment of NAS secondary to opioids. An algorithmic approach to the management of infants with NAS is suggested. Breastfeeding is not contraindicated in NAS, unless the mother is taking street drugs, is involved in polydrug abuse, or is infected with HIV. Future studies are required to assess the long-term effects of NAS on children after prenatal exposure.
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Affiliation(s)
- Prabhakar Kocherlakota
- Division of Neonatology, Department of Pediatrics, Maria Fareri Children's Hospital at New York Medical College, Valhalla, New York
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Smirk CL, Bowman E, Doyle LW, Kamlin O. Home-based detoxification for neonatal abstinence syndrome reduces length of hospital admission without prolonging treatment. Acta Paediatr 2014; 103:601-4. [PMID: 24547949 DOI: 10.1111/apa.12603] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 09/16/2013] [Accepted: 02/12/2014] [Indexed: 12/31/2022]
Abstract
AIM Neonatal abstinence syndrome (NAS) is a drug withdrawal syndrome, secondary to in utero chemical exposure and characterised by tremor, irritability and feed intolerance. It often requires prolonged hospital treatment and separation of families. Outpatient therapy may reduce this burden, but current literature is sparse. This review aimed to evaluate the safety and efficacy of our home-based detoxification programme and compare it with standard inpatient care. METHODS Infants requiring treatment for NAS between January 2004 and December 2010 were reviewed. Data on demographics, drug exposure, length of stay and type of therapy were compared between infants selected for home-based therapy and those treated conventionally. RESULTS Of the 118 infants who were admitted for treatment of NAS, 38 (32%) were managed at home. Infants receiving home-based detoxification had shorter hospital stays (mean 19 days vs. 39 days), with no increase in total duration of treatment (mean 36 days vs. 41 days), and were more likely to be breastfeeding on discharge from hospital care (45% vs. 22%). CONCLUSION In selected infants, home-based detoxification is associated with reduced hospital stays and increased rates of breastfeeding, without prolonging therapy. Safety of the infants remains paramount, which precludes many from entering such a programme.
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Affiliation(s)
- Cameron L. Smirk
- Department of Newborn Services; Royal Women's Hospital; Parkville VIC Australia
| | - Ellen Bowman
- Women's Alcohol and Drug Service; Royal Women's Hospital; Parkville VIC Australia
| | - Lex W. Doyle
- Newborn Research; Royal Women's Hospital; Parkville VIC Australia
- Department of Obstetrics and Gynaecology; University of Melbourne; Parkville VIC Australia
| | - Omar Kamlin
- Department of Newborn Services; Royal Women's Hospital; Parkville VIC Australia
- Newborn Research; Royal Women's Hospital; Parkville VIC Australia
- Department of Obstetrics and Gynaecology; University of Melbourne; Parkville VIC Australia
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Smirk CL, Bowman E, Doyle LW, Kamlin COF. How long should infants at risk of drug withdrawal be monitored after birth? J Paediatr Child Health 2014; 50:352-5. [PMID: 24628977 DOI: 10.1111/jpc.12513] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2013] [Indexed: 11/30/2022]
Abstract
AIM Neonatal abstinence syndrome (NAS) is an increasingly common disorder diagnosed in infants exposed to various drugs, causing immense financial and social burden. Recommendations from various bodies are for babies to be monitored for 4 to 7 days following birth so that prompt treatment can commence should symptoms develop. We aimed to determine the best post-natal observation period in babies at risk of NAS. METHODS A retrospective review was undertaken of infants ≥35 weeks' gestation who received treatment for NAS in the period 2001-2010. During this time, the standard post-natal observation period was a minimum of 7 days. Data including drug exposure, day of admission and day of treatment were collected. RESULTS Two hundred and ten babies were included. Drug exposure was predominantly to opiates (99%); however, most infants (58%) were exposed to additional substances (benzodiazepines, cannabis or amphetamines). Ninety-five per cent of infants were admitted by day 5 of life. Of the babies treated by day 7, 98.5% had been admitted to the nursery by day 5. Infants with polydrug exposure were admitted significantly earlier; however, time to treatment was not significantly different to those exposed to opiate replacement therapy alone. CONCLUSIONS In our hospital, babies treated for NAS often required admission before day 5. This has implications for hospital resource allocation, suggesting that routine post-natal observation for NAS could be shortened to 5 days. Further research is needed to help identify neonates who require more careful post-natal observation.
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Abstract
Substance use is prevalent in the United States, especially in the reproductive age population. Even though a reduction in substance use may occur during pregnancy, some women may not alter their drug use patterns until at least pregnancy is confirmed. For these reasons, a large number of fetuses are exposed to illicit substances, including during critical stages of organogenesis. Associating illicit drug use with eventual pregnancy outcome is difficult. This article presents issues pertaining to limitations with published investigations about fetal risks and describes the most current information in humans about fetal effects from specific illicit substances.
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Affiliation(s)
- Bradley D Holbrook
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, MSC10 5580, 1 University of New Mexico, Albuquerque, NM 87131-0001, USA.
| | - William F Rayburn
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, MSC10 5580, 1 University of New Mexico, Albuquerque, NM 87131-0001, USA
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McDonnell‐Dowling K, Donlon M, Kelly JP. Methamphetamine exposure during pregnancy at pharmacological doses produces neurodevelopmental and behavioural effects in rat offspring. Int J Dev Neurosci 2014; 35:42-51. [DOI: 10.1016/j.ijdevneu.2014.03.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Revised: 02/17/2014] [Accepted: 03/12/2014] [Indexed: 11/16/2022] Open
Affiliation(s)
- Kate McDonnell‐Dowling
- Discipline of Pharmacology and TherapeuticsSchool of MedicineNational University of IrelandGalwayIreland
| | - Michelle Donlon
- Discipline of Pharmacology and TherapeuticsSchool of MedicineNational University of IrelandGalwayIreland
| | - John P. Kelly
- Discipline of Pharmacology and TherapeuticsSchool of MedicineNational University of IrelandGalwayIreland
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Abstract
Most infants at risk for neonatal abstinence syndrome have opioid plus another drug exposure; polypharmacy is the rule rather than the exception. Scales for evaluation of neonatal abstinence syndrome are primarily based for opioid withdrawal. A standard protocol to treat neonatal abstinence syndrome has not been developed. Institute nonpharmacologic strategies for all neonates at risk. The American Academy of Pediatrics recommends mechanism-directed therapy (treat opioid withdrawal with an opioid) as the first-line therapy. Second-line medications are currently under evaluation.
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Affiliation(s)
- Kendra Grim
- Department of Anesthesiology, College of Medicine, Mayo Clinic, 200 First Street, Southwest, Rochester, MN 55902, USA
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Patel P, Abdel-Latif ME, Hazelton B, Wodak A, Chen J, Emsley F, Feller JM, Lui K, Oei JL. Perinatal outcomes of Australian buprenorphine-exposed mothers and their newborn infants. J Paediatr Child Health 2013; 49:746-53. [PMID: 23745982 DOI: 10.1111/jpc.12264] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2013] [Indexed: 11/30/2022]
Abstract
AIM To determine the short-term outcomes of Australian buprenorphine-exposed mother/infant dyads. METHODS Retrospective record review of drug-exposed mothers and infants in Australia. Groups were based on drug exposure: buprenorphine (55, 3.8%), non-buprenorphine opiates (O, 686, 48.6%) and non-opiates (NO, 671, 47.5%). RESULTS More than 30% of buprenorphine mothers continued to use heroin (21, 38%) and benzodiazepines (16, 29%). They were more likely to have child at risk concerns (29, 52.7%, P = 0.019) and have previous children placed in out-of-home care (9, 16.3%, P = 049). Buprenorphine babies were less likely to be preterm (16% vs. 25% (O), P = 0.001 and 23% (NO), P = 0.004) and had higher birthweights (median: 3165 g vs. 2842.5 g (O), P < 0.001 and 2900 g (NO), P = 0.004). Buprenorphine and non-buprenorphine opioid babies had similar maximum Finnegan scores (median 10 vs. 11(O), P = 0.144). The number of babies needing abstinence treatment (45% vs. 51% (O), P = 0.411) and length of hospital stay (median days 9 vs. 11(O), P = 0.067) were similar, but buprenorphine infants required lower maximum morphine doses (mg/kg/day) (median 0.4 mg vs. 0.5 mg (O), P = 0.009). CONCLUSIONS Short-term medical outcomes of infants of buprenorphine-using mothers are similar to those of non-buprenorphine opiate-using mothers, but interpretation of these results is confounded by the high rates of polydrug exposure in the buprenorphine group. This and other social concerns noted in buprenorphine mothers and infants warrant further study.
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Affiliation(s)
- Pankaj Patel
- The Department of Newborn Care, Royal Hospital for Women, Sydney, New South Wales, Australia
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25
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Abstract
All prenatal care providers should offer routine voluntary substance use screening to all patients. Parturients who screen positive for illicit substances require a multidisciplinary team approach to drug rehabilitation and prenatal care. This review will examine the pharmacological properties and the neonatal consequences of the use of opioids and amphetamines. Substance-abusing parturients typically abuse multiple substances simultaneously and have other comorbidities including psychosocial instability and mental illness. These comorbidities must be effectively addressed to achieve optimal health outcomes for both mother and infant.
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The relationship between maternal opioid agonists and psychiatric medications on length of hospitalization for neonatal abstinence syndrome. J Addict Med 2013; 5:293-9. [PMID: 21857233 DOI: 10.1097/adm.0b013e3182266a3a] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To examine the relationship between maternal opioid agonists, methadone, or buprenorphine (BPH), and concurrent psychiatric medication use on length of hospitalization (LOS) among infants with neonatal abstinence syndrome (NAS). METHODS We reviewed the charts of infants born at Boston Medical Center between 2003 and 2009 with a diagnosis of NAS whose mothers were prescribed methadone or BPH for opiate addiction. Univariate and multivariate linear regression analyses were used to examine associations between maternal opioid substitution concurrent with psychiatric medication use and infant LOS. We also tested whether exposure to BPH was associated with a shorter hospitalization. RESULTS A total of 273 mother-infant pairs were identified. The average LOS for all infants was 22.9 days (SD: 10.9). In bivariate analyses, maternal use of any psychiatric medication was associated with a longer infant LOS (P < 0.005). Compared with those prescribed methadone alone (n = 158), those also taking benzodiazepines (n = 56) had a 5.88-day longer LOS (95% confidence interval [CI]: 2.15-9.60, P = 0.002). Infants of mothers taking methadone plus an selective serotonin re-uptake inhibitor (n = 51) had a longer LOS (β = 4.47, 95% CI: 1.15-7.79) compared to methadone alone; results remained significant in an initial multivariate model, however the effect was attenuated when additional psychiatric medication use was added to the model. Compared with those exposed to methadone, those exposed to BPH (n = 22) had a significantly shorter LOS (ß = -7.35, CI: -0.18 to -14.52, P = 0.04). CONCLUSIONS Maternal use of prescribed methadone and benzodiazepines, compared to methadone alone, increased LOS for infants with NAS by 6 days. Maternal use of BPH was associated with a shorter LOS.
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Abstract
Recent rise in rates of opiate replacement therapy among pregnant women have resulted in increasing number of infants requiring treatment for neonatal abstinence syndrome (NAS). Short-term and long-term developmental outcomes associated with prenatal opiate exposure are discussed, including symptoms and severity of NAS, and early cognitive and motor delays. Maternal and infant risk factors are discussed, and include patterns of maternal substance use during pregnancy, genetic risk, polysubstance exposure pharmacological treatment for NAS and breastfeeding. The importance of characterizing corollary environmental risk factors is also considered.
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Affiliation(s)
- Beth A. Logan
- University of Maine, Graduate School of Biomedical Sciences and Department of Psychology, Orono, Maine 04469
| | - Mark S. Brown
- Chief of Pediatrics and Director of Nurseries, Eastern Maine Medical Center, Bangor, Maine 04401
| | - Marie J. Hayes
- University of Maine, Graduate School of Biomedical Sciences and Department of Psychology, Orono, Maine 04469
- Allied Scientist, Eastern Maine Healthcare Systems, Bangor, Maine 04401
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Abdel-Latif ME, Oei J, Craig F, Lui K. Profile of infants born to drug-using mothers: a state-wide audit. J Paediatr Child Health 2013; 49:E80-6. [PMID: 22530812 DOI: 10.1111/j.1440-1754.2012.02471.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
AIMS To ascertain the characteristics and short-term outcomes of infants born to illicit drug-using mothers in public hospitals in the state of New South Wales and the Australian Capital Territory during 2004. METHODS Patients were identified retrospectively by hospital records searches using ICD-10 morbidity codes and records of local Drug and Alcohol Services. Records were reviewed on site. All public hospitals (n= 101) with obstetric services were included. RESULTS A total of 879 (1.4%, 95% confidence interval: 1.3-1.5%) drug-using mothers were identified from 62,682 confinements. Opiates (46.8%), amphetamines (23.0%) and polydrug (16.4%) exposure were most common. There were eight stillbirths. Among these 871 infants, prematurity (23.6%) and low birthweight (27.1%) were common and 51.1% were admitted to nurseries for further care. Two infants died. Major congenital anomalies were detected in 15 infants. Pharmacological treatment for withdrawal was required for 202 (23.2%), and 143 (70.8%) infants were discharged home on medication. Infants who completed inpatient pharmacological treatment were hospitalised longer (median 26.0 vs. 12.0 days) and were more likely to be premature (37.3 vs. 14.0%). Child-at-risk notifications affected 40.6% of the infants, and 7.6% were fostered prior to discharge. A total of 333 (38.2%) infants were breastfed at discharge. CONCLUSIONS Our regional study highlights a substantial prevalence of drug use in pregnancy with considerable adverse perinatal and hospital outcomes in infants born to these mothers. Coordinated health care and resources are needed to support these mother-infant pairs because of their social, medical and mental-health issues.
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Affiliation(s)
- Mohamed E Abdel-Latif
- Department of Neonatology, The Canberra Hospital, Garran, Australian Capital Territory, Australia
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29
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Abstract
Opioid use in pregnant women has increased over the last decade. Following birth, infants with in utero exposure demonstrate signs and symptoms of withdrawal known as the neonatal abstinence syndrome (NAS). Infants express a spectrum of disease, with most requiring the administration of pharmacologic therapy to ensure proper growth and development. Treatment often involves prolonged hospitalization. There is a general lack of high-quality clinical trial data to guide optimal therapy, and significant heterogeneity in treatment approaches. Emerging trends in the treatment of infants with NAS include the use of sublingual buprenorphine, transition to outpatient therapy, and pharmacogenetic risk stratification.
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Affiliation(s)
- Walter K Kraft
- Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, 1170 Main Building, 132 South 10th Street, Philadelphia, PA 19107, USA.
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30
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Pritham UA, Paul JA, Hayes MJ. Opioid dependency in pregnancy and length of stay for neonatal abstinence syndrome. J Obstet Gynecol Neonatal Nurs 2012; 41:180-190. [PMID: 22375882 PMCID: PMC3407283 DOI: 10.1111/j.1552-6909.2011.01330.x] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine opioid replacement therapy in pregnancy and effect on neonatal outcomes, including length of hospital stay for neonatal abstinence syndrome. DESIGN Retrospective descriptive study. SETTING Labor and delivery unit and neonatal intensive care unit (NICU), Eastern Maine Medical Center, Bangor, Maine. PARTICIPANTS One hundred fifty-two opioid-dependent pregnant women on methadone maintenance therapy (MMT) (n = 136) or buprenorphine maintenance therapy (BMT) (n = 16) during pregnancy and their neonates. The neonates were born between January 1, 2005 and December 31, 2007. METHODS A review of the electronic medical record (EMR) was conducted of all opioid-dependent women who were maintained on MMT or BMT at the time of admission for labor and delivery and their neonates. RESULTS Maternal methadone dose and concomitant in-utero exposure to benzodiazepines prolonged the length of hospital stay for neonates. Length of stay was shorter in breastfed neonates than formula-fed neonates or neonates who received formula and breast milk. Neonates with prenatal exposure to MMT spent more days in the hospital (21 vs. 14 days) for treatment of neonatal abstinence syndrome (NAS) than infants with prenatal exposure to BMT. CONCLUSION These findings are consistent with previous research on the simultaneous use of methadone and benzodiazepines during pregnancy and provide further direction for the treatment of opioid dependency during pregnancy. Harm reduction strategies for opioid-dependent pregnant women in substance abuse treatment with MMT may one day include guidance on daily treatment doses and recommendations to avoid the concomitant use of benzodiazepines to lessen NAS. Breastfeeding should be recommended to shorten length of stay. Understanding perinatal and neonatal outcomes of pregnant women on methadone or buprenorphine will help to identify optimal treatment for opioid dependency in pregnancy.
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Affiliation(s)
- Ursula A Pritham
- School of Nursing, Georgia Southern University, Statesboro, GA..
| | - Jonathan A Paul
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX
| | - Marie J Hayes
- Department of Psychology, University of Maine, Orono, ME
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Pharmacological treatment of neonatal opiate withdrawal: between the devil and the deep blue sea. Int J Pediatr 2011; 2011:935631. [PMID: 21760818 PMCID: PMC3133472 DOI: 10.1155/2011/935631] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Revised: 02/18/2011] [Accepted: 03/28/2011] [Indexed: 11/17/2022] Open
Abstract
Illicit drug use with opiates in pregnancy is a major global health issue with neonatal withdrawal being a common complication. Morphine is the main pharmacological agent administered for the treatment of neonatal withdrawal. In the past, morphine has been considered by and large inert in terms of its long-term effects on the central nervous system. However, recent animal and clinical studies have demonstrated that opiates exhibit significant effects on the growing brain. This includes direct dose-dependent effects on reduction in brain size and weight, protein, DNA, RNA, and neurotransmitters—possibly as a direct consequence of a number of opiate-mediated systems that influence neural cell differentiation, proliferation, and apoptosis. At this stage, we are stuck between the devil and the deep blue sea. There are no real alternatives to pharmacological treatment with opiates and other drugs for neonatal opiate withdrawal and opiate addiction in pregnant women. However, pending further rigorous studies examining the potential harmful effects of opiate exposure in utero and the perinatal period, prolonged use of these agents in the neonatal period should be used judiciously, with caution, and avoided where possible.
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Breast Milk Hydrocodone and Hydromorphone Levels in Mothers Using Hydrocodone for Postpartum Pain. Obstet Gynecol 2011; 117:611-617. [DOI: 10.1097/aog.0b013e31820ca504] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Goel N, Beasley D, Rajkumar V, Banerjee S. Perinatal outcome of illicit substance use in pregnancy--comparative and contemporary socio-clinical profile in the UK. Eur J Pediatr 2011; 170:199-205. [PMID: 20827558 DOI: 10.1007/s00431-010-1284-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2010] [Accepted: 08/17/2010] [Indexed: 01/07/2023]
Abstract
The aim of the study was to determine the contemporary socio-clinical profile and perinatal outcome of illicit substance use in pregnancy in a large UK city and compare with published literature. Cases were identified retrospectively from the 'cause for concern' referrals over 5 years (2003-2007). Data was collected on mother-infant pair from medical notes and laboratory records. Chi-square and Mann-Whitney U tests were used where appropriate for statistical analysis. One hundred sixty-eight women were identified as using illicit substance in pregnancy. Smoking (97.4%), unemployment (85.4%) and single status (42.3%) were frequent. Besides controlled use of methadone, heroin, cannabis and benzodiazepines were the most commonly used drugs. Hepatitis C prevalence was high (29.9%) despite low antenatal screening rates (57.7%). Neonatal morbidity was related to prematurity (22.9%), small for dates (28.6%) and neonatal abstinence syndrome (NAS; 58.9%). By day 5 of life, 95.1% of the babies developing NAS and 96.1% of those requiring pharmacological treatment were symptomatic. Of the infants developing NAS, 31.7% required pharmacological treatment. A total of 82.5% babies went home with their mother, and 21.2% were placed on the Child Protection Register. Only 14.3% were breast feeding at discharge. Illicit substance use in pregnancy continues to be associated with significant maternal and neonatal morbidity, and the socio-clinical profile in this decade appears unchanged in the UK. Hepatitis C prevalence is high, and detection should be improved through targeted antenatal screening. Where facility in the community is unavailable, 5 days of hospital stay is sufficient to safely identify babies at risk of developing NAS. Most babies were discharged home with their mother.
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Affiliation(s)
- Nitin Goel
- Department of Neonatal Medicine, Division of Women and Child Health, ABM University Health Board, Singleton Hospital, Sketty Lane, Swansea SA2 8QA, UK.
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Maternal and neonatal factors impacting response to methadone therapy in infants treated for neonatal abstinence syndrome. J Perinatol 2011; 31:25-9. [PMID: 20508596 DOI: 10.1038/jp.2010.66] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To identify maternal and neonatal factors that impact response to methadone therapy for neonatal abstinence syndrome. STUDY DESIGN This is a retrospective review of 128 infants that received pharmacotherapy for opiate withdrawal to identify factors associated with favorable response to methadone therapy. Maternal and neonatal data were analyzed with univariate statistics and multivariate logistic regression. RESULT Maternal methadone maintenance dose during pregnancy correlated with length of stay (P=0.009). There was an inverse correlation between the amount of mother's breast milk ingested and length of stay (β=-0.03, P=0.02). Methadone was initiated later, tapered more rapidly and was more successful as monotherapy in preterm infants. Five percent of infants were admitted to hospital again for rebound withdrawal following reduction of breast milk intake. CONCLUSION Severity of neonatal abstinence syndrome may be mitigated by titrating methadone to the lowest effective dose during pregnancy and by encouraging breast milk feeds, which should be weaned gradually.
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Seligman NS, Almario CV, Hayes EJ, Dysart KC, Berghella V, Baxter JK. Relationship between maternal methadone dose at delivery and neonatal abstinence syndrome. J Pediatr 2010; 157:428-33, 433.e1. [PMID: 20472252 DOI: 10.1016/j.jpeds.2010.03.033] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2009] [Revised: 02/08/2010] [Accepted: 03/26/2010] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To estimate the relationship between maternal methadone dose and the incidence of neonatal abstinence syndrome (NAS). STUDY DESIGN We performed a retrospective cohort study of pregnant women treated with methadone for opiate addiction who delivered live-born neonates between 1996 and 2006. Four dose groups, on the basis of total daily methadone dose, were compared (<or=80 mg/d, 81-120 mg/d, 121-160 mg/d, and >160 mg/d). The primary outcome was treatment for NAS. Symptoms of NAS were objectively measured with the Finnegan scoring system, and treatment was initiated for a score>24 during the prior 24 hours. RESULTS A total of 330 women treated with methadone and their 388 offspring were included. Average methadone dose at delivery was 117+/-50 mg/d (range, 20-340 mg/d). Overall, 68% of infants were treated for NAS. Of infants exposed to methadone doses<or=80 mg/d, 81-120 mg/d, 121-160 mg/d, and >160 mg/d, treatment for NAS was initiated for 68%, 63%, 70%, and 73% of neonates, respectively (P=.48). The rate of maternal illicit opiate abuse at delivery was 26%, 28%, 19%, and 11%, respectively (P=.04). CONCLUSION No correlation was found between maternal methadone dose and rate of NAS. However, higher doses of methadone were associated with decreased illicit opiate abuse at delivery.
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Affiliation(s)
- Neil S Seligman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA 19107, USA.
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Sadeu JC, Hughes CL, Agarwal S, Foster WG. Alcohol, drugs, caffeine, tobacco, and environmental contaminant exposure: reproductive health consequences and clinical implications. Crit Rev Toxicol 2010; 40:633-52. [PMID: 20662712 DOI: 10.3109/10408444.2010.493552] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Reproductive function and fertility are thought to be compromised by behaviors such as cigarette smoking, substance abuse, and alcohol consumption; however, the strength of these associations are uncertain. Furthermore, the reproductive system is thought to be under attack from exposure to environmental contaminants, particularly those chemicals shown to affect endocrine homeostasis. The relationship between exposure to environmental contaminants and adverse effects on human reproductive health are frequently debated in the scientific literature and these controversies have spread into the lay press drawing increased public and regulatory attention. Therefore, the objective of the present review was to critically evaluate the literature concerning the relationship between lifestyle exposures and adverse effects on fertility as well as examining the evidence for a role of environmental contaminants in the purported decline of semen quality and the pathophysiology of subfertility, polycystic ovarian syndrome, and endometriosis. The authors conclude that whereas cigarette smoking is strongly associated with adverse reproductive outcomes, high-level exposures to other lifestyle factors are only weakly linked with negative fertility impacts. Finally, there is no compelling evidence that environmental contaminants, at concentrations representative of the levels measured in contemporary biomonitoring studies, have any effect, positive or negative, on reproductive health in the general population. Further research using prospective study designs with robust sample sizes are needed to evaluate testable hypotheses that address the relationship between exposure and adverse reproductive health effects.
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Affiliation(s)
- J C Sadeu
- Reproductive Biology Division, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
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37
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PONG KM, ABDEL-LATIF ME, LUI K, WODAK AD, FELLER JM, CAMPBELL T, OEI J. The temporal influence of a heroin shortage on pregnant drug users and their newborn infants in Sydney, Australia. Aust N Z J Obstet Gynaecol 2010; 50:230-6. [DOI: 10.1111/j.1479-828x.2010.01146.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Prenatal care reduces the impact of illicit drug use on perinatal outcomes. Women who misuse substances are often excluded from mainstream society and, on becoming pregnant, feel guilty about their drug misuse and the potential effects this could have on their unborn baby. These women are vulnerable in many ways and agencies must ensure that they are not excluded from antenatal care. The latest enquiry into maternal deaths published in the UK (CEMACH report) highlights how women with socially complex lives who died were far less likely to have sought antenatal care early in pregnancy or to remain in regular contact with maternity services. Of the women who died from any cause, 11% had problems with substance abuse of whom 60% were registered addicts. Gaps in communication between agencies was highlighted as a particular problem.
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Vucinovic M, Roje D, Vucinovic Z, Capkun V, Bucat M, Banovic I. Maternal and neonatal effects of substance abuse during pregnancy: our ten-year experience. Yonsei Med J 2008; 49:705-13. [PMID: 18972589 PMCID: PMC2615365 DOI: 10.3349/ymj.2008.49.5.705] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
PURPOSE The aim of the study was to assess perinatal outcome of pregnancy burdened with maternal addiction in comparison with an unselected population from a European transition country. MATERIALS AND METHODS Data on pregnancies complicated by illicit drug abuse (n = 85) managed during a 10-year period (1997-2007) at Split University Hospital were analyzed. Data on the type of drug, course of gestation and labor, and on perinatal outcome were considered. Data on all non-dependence pregnancies recorded during the study period were used as a control group. RESULTS During the study period, there were 85 dependence-complicated pregnancies (0.2%). Use of heroin alone during pregnancy was recorded in 51 women (50%), methadone alone in 6 (7%), and a combination of heroin and methadone in 9 (11%). Premature delivery was significantly more common in the group of pregnant addicts (21% vs. 6%); 49% of pregnant addicts were carriers of hepatitis C virus (HCV) and 14% of hepatitis B virus (HBV). Neonatal abstinence syndrome developed in 61 infants (7%) born to addicted mothers. There were 4 cases (4.6%) of early neonatal death; 7 neonates had 5-minute Apgar score < or = 7 (8%); 29 neonates had low birth weight for age (33%); and 7 neonates had congenital anomalies (8%). The risk of various congenital anomalies was 3-fold in the group of children born to addicted mothers. CONCLUSION Addiction pregnancies present a small but high-risk group according to perinatal outcome. Appropriate obstetric and neonatal care can reduce the rate of complications in these pregnancies and improve perinatal outcome.
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Affiliation(s)
- Mirjana Vucinovic
- Neonatal Intensive Care Unit, Department of Obstetrics and Gynecology, Split University Hospital, Split, Croatia.
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Seligman NS, Salva N, Hayes EJ, Dysart KC, Pequignot EC, Baxter JK. Predicting length of treatment for neonatal abstinence syndrome in methadone-exposed neonates. Am J Obstet Gynecol 2008; 199:396.e1-7. [PMID: 18928986 DOI: 10.1016/j.ajog.2008.06.088] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2008] [Revised: 05/01/2008] [Accepted: 06/25/2008] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of the study was to identify maternal variables predicting length of treatment for neonatal abstinence syndrome (NAS). STUDY DESIGN This was a retrospective cohort study of infants treated for NAS during 2000-2006 whose mothers were on methadone maintenance at delivery. Mixed-effects linear regression was used to examine the interaction of maternal and neonatal variables with length of treatment. RESULTS Of 204 neonates born to methadone exposed mothers, the average dose at delivery was 127 mg daily (25-340 mg) with median length of treatment 32 days (1-122 days). Trimester of initial exposure (P = .33), methadone dose at delivery (P = .198), body mass index (P = .31), antidepressant use (P = .40), cigarette use (P = .76), race (P = .78), and maternal age (P = .84) did not predict length of treatment. In the multivariate analysis, gestational age at delivery and benzodiazepine use were significant predictors of length of treatment. CONCLUSION Later gestational age and concomitant benzodiazepine use were associated with longer treatment.
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Affiliation(s)
- Neil S Seligman
- Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA 19107, USA.
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Abstract
PURPOSE OF REVIEW The present article is an update on the effects of drug abuse on pregnancy outcome. RECENT FINDINGS Substance abuse in pregnancy is on the increase worldwide. Simultaneously, there is great variability in prevalence rates in different countries, regions of countries and in different ethnic groups. In the United States nearly 90% of drug-abusing women are of reproductive age. Substances most commonly abused in pregnancy include cocaine, amphetamines, opioids, marijuana, ethanol, tobacco, caffeine, and toluene-based solvents. Polysubstance abuse is very common. SUMMARY Substance abuse in pregnancy is associated with significant maternal and fetal morbidity. Risk factors suggesting substance abuse in pregnancy include lack of prenatal care, history of premature labor, and cigarette smoking. In the United States the American College of Obstetricians and Gynecologists has made multiple recommendations regarding management of parturients with drug abuse during pregnancy. Women who acknowledge use of illicit substance during pregnancy should be counseled and offered necessary treatment. The American College of Obstetricians and Gynecologists also acknowledged that some states consider intrauterine fetal drug exposure to be a form of child neglect or abuse under the law.
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Current World Literature. Curr Opin Obstet Gynecol 2007; 19:596-605. [DOI: 10.1097/gco.0b013e3282f37e31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dowdell JA, Fenwick J, Bartu A, Sharp J. Midwives' descriptions of the postnatal experiences of women who use illicit substances: a descriptive study. Midwifery 2007; 25:295-306. [PMID: 17614166 DOI: 10.1016/j.midw.2007.03.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2006] [Revised: 02/12/2007] [Accepted: 03/29/2007] [Indexed: 11/17/2022]
Abstract
OBJECTIVES to describe midwives' perceptions of the early mothering experiences of 20 Australian illicit-drug-using mothers. DESIGN a qualitative retrospective study using an explorative descriptive design. Twenty client records, completed by research midwives over 6 months (with follow-up visits at 12 and 18 months), formed the data set. Thematic analysis and the techniques associated with constant comparison were used to analyse the data. SETTING Perth, Western Australia. PARTICIPANTS twenty postpartum women with a history of using illicit drugs. FINDINGS seven major themes were identified that described how childbearing women with drug problems strive to be 'normal mums' although living on the fringe of society. The first three major themes were labelled; Baby as the priority; Hating the body: and Life sucks. Theme four represents the level of family and community support available, which had the potential to facilitate and/or hinder the experience. The analysis suggested that women who had good support, particularly at 4 months postpartum and beyond, were more likely to move towards the fifth theme Hanging in there: striving to be a normal mum. Women with minimal support, living in hostile and often abusive environments, gravitated towards the theme of Beyond caring with the eventual consequence being chaos and a return to heavy drug use, labelled Emotional fibrillation. CONCLUSION very few women were using drugs early in the postnatal period. These new mothers made every effort to prioritise the needs of their newborns, often within a context of abusive relationships, poor emotional well-being and financial hardship. High levels of physical and psychological morbidity were related to psychosocial factors as opposed to drug use alone. By 4 months postpartum, there was evidence that women were becoming increasingly vulnerable to the challenges of their lives. Family and community support played a role in how this group of women moved through their mothering experience. IMPLICATIONS FOR PRACTICE the range of health, social and support services required by new mothers when they are using illicit drugs is substantial. Collaboration and coordination between agencies is crucial for quality outcomes. Fostering positive relationships with drug-using pregnant women and maintaining these links into the extended postnatal period may be one strategy that would improve the integration of services and ensure that women stay engaged with the system.
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Affiliation(s)
- Julie Anne Dowdell
- Curtin University of Technology, School of Nursing and Midwifery, GPO Box U1987, Perth, WA 6845, Australia
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