Breastfeeding rates and the relationship between breastfeeding and neonatal abstinence syndrome in women maintained on buprenorphine during pregnancy

Factors associated with medications for opioid use disorder (MOUD) treatment success during the pregnancy and postpartum periods: A scoping review

BACKGROUND

Medications for opioid use disorder (MOUD) are a crucial intervention for pregnant and postpartum individuals with opioid use disorder (OUD). However, there is paucity of data on the factors associated with MOUD treatment success in this population. This scoping review aimed to evaluate factors associated with MOUD success during the pregnancy and postpartum period.

METHODS

We completed a structured search of MEDLINE, CINAHL, PsycINFO, Web of Science, and ProQuest databases. Eligible studies included a metric of success in outpatient treatment in the pregnancy and postpartum period and were conducted in the United States after the Food and Drug Administration's approval of buprenorphine in 2002. Reviewers independently screened studies for inclusion and extracted data. The primary outcome was treatment success (i.e., treatment adherence, abstinence from illicit opioids, or retention in care) during pregnancy and up to 12 months postpartum.

RESULTS

Data from 15 studies were included. Medications included methadone, naltrexone and buprenorphine (mono or combination therapy). High daily dose of buprenorphine as mono or combination therapy, early initiation and longer duration of MOUD were associated with treatment success. Legal involvement, homelessness, and rural residency were negatively associated with treatment success. There were no differences in outcomes of individuals receiving telemedicine versus in-person care.

CONCLUSION

We identified several factors associated with MOUD treatment success among individuals with OUD during the pregnancy and postpartum periods. These factors may help guide future research and inform the development and adaptation of interventions tailored to better meet the needs of this key population.

Oral Feeding Outcomes in Infants Born With Neonatal Abstinence Syndrome

OBJECTIVE

Breastfeeding is the optimal source of nutrition for all infants, but there are limited data on feeding outcomes in infants with neonatal abstinence syndrome (NAS) who are admitted in the neonatal intensive care unit (NICU).

METHODS

A retrospective cohort study was conducted at a level II/III NICU. Study sample consisted infants with a diagnosis of NAS and those diagnosed with respiratory distress syndrome. The primary outcome was attainment of independent oral feeds, defined as the number of days to transition from full-tube to full oral feeds. Secondary outcomes included length of hospital stay and method (breast or bottle) of oral feeds at the start, at attainment of independent oral feeds, and at hospital discharge.

RESULTS

Infants with NAS took significantly longer to attain independent oral feeds than controls ( P = .021) and received significantly fewer breastfeeds at the start of oral feeds, at independent oral feeds, and at hospital discharge ( P = .000). There was no difference in length of hospital stay between groups.

CONCLUSION

These results suggest that infants with NAS can experience difficulties achieving independent oral feeds and are less likely to receive breastfeeds. Additional support is required to enhance oral feeds in infants with NAS in the NICU.

Academy of Breastfeeding Medicine Clinical Protocol #21: Breastfeeding in the Setting of Substance Use and Substance Use Disorder (Revised 2023)

Background: The Academy of Breastfeeding Medicine (ABM) revised the 2015 version of the substance use disorder (SUD) clinical protocol to review the evidence and provide updated literature-based recommendations related to breastfeeding in the setting of substance use and SUD treatments. Key Information: Decisions around breastfeeding are an important aspect of care during the peripartum period, and there are specific benefits and risks for substance-exposed mother-infant dyads. Recommendations: This protocol provides breastfeeding recommendations in the setting of nonprescribed opioid, stimulant, sedative-hypnotic, alcohol, nicotine, and cannabis use, and SUD treatments. Additionally, we offer guidance on the utility of toxicology testing in breastfeeding recommendations. Individual programs and institutions should establish consistent breastfeeding approaches that mitigate bias, facilitate consistency, and empower mothers with SUD. For specific breastfeeding recommendations, given the complexity of breastfeeding in mothers with SUD, individualized care plans should be created in partnership with the patient and multidisciplinary team with appropriate clinical support and follow-up. In general, breastfeeding is recommended among mothers who stop nonprescribed substance use by the time of delivery, and they should continue to receive ongoing postpartum care, such as lactation support and SUD treatment. Overall, enhancing breastfeeding education regarding substance use in pregnancy and lactation is essential to allow for patient-centered guidance.

Use of Psychoactive Substances during the Perinatal Period: Guidelines for Interventions during the Perinatal Period from the French National College of Midwives

Based on their clinical practice and an extensive review of the literature, the authors propose a framework of procedures to be followed to provide services to all women of childbearing age who use psychoactive substances (alcohol, cannabis, cocaine, amphetamines, and opioids), especially during pregnancy or during the postpartum and breastfeeding periods, in view of their individual situations and environmental contexts.

Neonatal abstinence syndrome and mother's own milk at discharge

OBJECTIVE

To describe factors impacting receipt of mother's own milk (MOM) at discharge among California infants diagnosed with neonatal abstinence syndrome (NAS).

STUDY DESIGN

Cohort study of the California Perinatal Quality Care Collaborative's Maternal Substance Exposure Database for infants with NAS and gestational age ≥ 34 weeks from 2019 to 2020.

RESULT

245 infants with NAS were identified. Variables with an increased likelihood of being discharged on MOM included maternal medication assisted treatment (p = 0.001), use of maternal addiction services (p < 0.001), receiving donor human milk (p = 0.001), being treated in the well baby unit (p < 0.001), rooming-in (p < 0.001), and kangaroo care (p < 0.001). Among infants with NAS for whom MOM was recommended (n = 84), rooming-in was the only factor associated with being discharged on MOM (p = 0.002); receiving formula was the only inversely associated factor (p < 0.001).

CONCLUSION

Results suggest supporting the mother-infant dyad and using non-pharmacologic treatment methods, such as rooming-in, increase receipt of MOM at discharge.

Technical Report: Breastfeeding and the Use of Human Milk

Breastfeeding and human milk are the normative standards for infant feeding and nutrition. The short- and long-term medical and neurodevelopmental advantages of breastfeeding make breastfeeding or the provision of human milk a public health imperative. The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for approximately 6 months after birth. Furthermore, the AAP supports continued breastfeeding, along with appropriate complementary foods introduced at about 6 months, as long as mutually desired by mother and child for 2 years or beyond. These recommendations are consistent with those of the World Health Organization (WHO). Medical contraindications to breastfeeding are rare. The AAP recommends that birth hospitals or centers implement maternity care practices shown to improve breastfeeding initiation, duration, and exclusivity. The Centers for Disease Control and Prevention and The Joint Commission monitor breastfeeding practices in United States hospitals. Pediatricians play a critical role in hospitals, their practices, and communities as advocates of breastfeeding and, thus, need to be trained about the benefits of breastfeeding for mothers and children and in managing breastfeeding. Efforts to improve breastfeeding rates must acknowledge existing disparities and the impact of racism in promoting equity in breastfeeding education, support, and services.

Unpacking Perinatal Experiences with Opioid Use Disorder: Relapse Risk Implications

While pregnancy presents a strong motivation to seek and comply with treatment for opioid use disorder (OUD), many women relapse within the first year of childbirth. Addressing relapse risk, we examined the perinatal experiences of mothers with OUD through 6 months postpartum. We recruited mothers (N = 42) with a history of OUD into the Newborn Attachment and Wellness study, all of whom met with a child welfare worker immediately after giving birth. In qualitative interviews, mothers described their social, physical, emotional, and psychological perinatal experiences. Seven themes categorically informed relapse risk (i.e., related to childhood bond, mother-infant attachment, birth support, child protective services, breastfeeding, mental health, and recovery planning). In conclusion, we noted a critical window in which clinical social workers and other health/behavioral health providers have the opportunity to capitalize on mothers' desire not to "ever want to touch it again." We outline specific avenues for directed support in the perinatal and postpartum period associated with reduced risk for relapse, and we make recommendations to enhance risk assessment practices.

Prenatal opioid-exposed infant extracellular miRNA signature obtained at birth predicts severity of neonatal opioid withdrawal syndrome

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.

Scoping Review of Barriers and Facilitators of Breastfeeding in Women on Opioid Maintenance Therapy

OBJECTIVE

To synthesize the literature on the barriers and facilitators of breastfeeding among women on opioid maintenance therapy (OMT) to inform nursing interventions and improve breastfeeding outcomes.

DATA SOURCES

We searched 11 databases using the following key terms: breastfeeding, barriers, facilitators, promotion, and opioid.

STUDY SELECTION

We included articles published in English since 2015 that addressed barriers and facilitators of breastfeeding in women on OMT. We did not limit our search to specific types of studies. Our search produced 65 records. After reviewing titles and abstracts, we assessed 21 full-text articles and excluded seven for lack of data related to our key terms. As a result, we included five qualitative studies, three reviews, three mixed-methods studies, two retrospective cohort studies, and one case report (14 articles) in our final review.

DATA EXTRACTION

We extracted data from each article and sorted them in a table for analysis and synthesis. Data included study purpose, research questions, design and methodology, and findings specifically pertaining to the identification of barriers and facilitators of breastfeeding for women on OMT.

DATA SYNTHESIS

We identified three themes related to facilitators of and barriers to breastfeeding: Information, Support, and Health Care System Factors.

CONCLUSION

The results of our review suggest that most barriers and facilitators of breastfeeding in women on OMT are manageable with improved health care practices. Primary and acute care health professionals should modify practices to minimize barriers to breastfeeding. Nurses should provide better breastfeeding education and preparation, sensitive care in the immediate postpartum period, and extended follow-up after hospital discharge for women on OMT.

A Meta-Analysis of Breastfeeding Effects for Infants With Neonatal Abstinence Syndrome

Supplemental digital content is available in the text.

Background

Neonatal abstinence syndrome (NAS) rates have dramatically increased. Breastfeeding is a nonpharmacological intervention that may be beneficial, reducing NAS symptom severity and thus the need for and duration of pharmacological treatment and length of hospital stay.

Objectives

Conduct meta-analysis to determine whether breastfeeding results in better outcomes for NAS infants. Variables included symptom severity, need for and duration of pharmacological treatment, and length of hospital stay.

Methods

PubMed, Scopus, Embase, and Cochrane Library were searched from 2000 to 2020, and comparative studies examining breastfeeding for NAS infants were extracted. Randomized trials and cohort studies were included. Data were extracted and evaluated with Review Manager Version 5.3. A random-effects model was used to pool discontinuous outcomes using risk ratio and 95% confidence intervals. Continuous outcomes were evaluated by mean differences and 95% confidence intervals.

Results

Across 11 studies, 6,375 neonates were included in the meta-analysis. Using a random-effects analysis, breastfeeding reduced initiation of pharmacological treatment, reduced duration of pharmacological treatment, and reduced length of stay. No differences were detected for severity of NAS symptoms. Most studies only reported one to two variables of interest. For most studies, these variables were not the primary study outcomes. All studies were found to be of low risk and good quality based on the Cochrane Risk Assessment Tools. Varying breastfeeding definitions limit generalizability.

Discussion

Breastfeeding is associated with decreased initiation and duration of pharmacological treatment and length of stay.

The Term Newborn: Prenatal Substance Exposure

Care for pregnant patients with substance use disorder must be provided in a nonjudgmental manner with recognition of addiction as a chronic medical illness in order to establish a therapeutic relationship and improve outcomes. All pregnant patients should be screened for substance use during prenatal care. Screening can be accomplished through several validated screening tools. Patients who screen positive need to be evaluated and referred for treatment as appropriate. This article reviews specific adverse perinatal outcomes associated with the use of a variety of substances and provides guidance on exposure with continued breastfeeding.

A Retrospective Cohort Study Examining the Utility of Perinatal Urine Toxicology Testing to Guide Breastfeeding Initiation

OBJECTIVE

National guidelines advise against breastfeeding for women who use nonprescribed substances in the third trimester. This reduces the number of women who are supported in breastfeeding initiation despite limited evidence on the prognostic value of third trimester substance use. We sought to examine the degree to which prenatal nonprescribed substance use is associated with non-prescribed use postpartum.

METHODS

Retrospective cohort study of pregnant women with opioid use disorder on methadone or buprenorphine between 2006 and 2015. Nonprescribed use was defined by a positive urine drug testing (UDT). Sensitivity, specificity, positive predictive value, and negative predictive value were calculated comparing 3 prenatal periods with postpartum UDT results. Generalized estimating equations were used to examine the extent to which prenatal nonprescribed use was associated with postpartum use.

RESULTS

Included were 545 deliveries by 503 women. Mean age was 28.3 years, 88% were White/non-Hispanic, 93% had public insurance, and 43% received adequate prenatal care. The predictive value of UDT's 90 to 31 days before delivery, 30 to 0 days before delivery, and at delivery showed low sensitivity (44, 26, 27%, respectively) and positive predictive value (36, 36, 56%, respectively), but higher negative predictive value (80, 85, and 78%, respectively), P-values all <0.05. In the final adjusted model, only nonprescribed use at delivery was significantly associated with postpartum nonprescribed use.

CONCLUSIONS

Nonprescribed use at delivery was most strongly associated with postpartum use compared with earlier time periods currently prioritized in guidelines. In women with opioid use disorder prenatal UDT results alone are insufficient to guide breastfeeding decisions.

Opioid use during pregnancy can impair maternal behavior and the Maternal Brain Network: A literature review

Opioid Use Disorder (OUD) is a global epidemic also affecting women of reproductive age. A standard form of pharmacological treatment for OUD is Opioid Maintenance Therapy (OMT) and buprenorphine has emerged as the preferred treatment for pregnant women with OUD relative to methadone. However, the consequences of BUP exposure on the developing Maternal Brain Network and mother-infant dyad are not well understood. The maternal-infant bond is dependent on the Maternal Brain Network, which is responsible for the dynamic transition from a "nulliparous brain" to a "maternal brain". The Maternal Brain Network consists of regions implicated in maternal care (e.g., medial preoptic area, nucleus accumbens, ventral pallidum, ventral tegmentum area) and maternal defense (e.g., periaqueductal gray). The endogenous opioid system modulates many of the neurochemical changes in these areas during the transition to motherhood. Thus, it is not surprising that exogenous opioid exposure during pregnancy can be disruptive to the Maternal Brain Network. Though less drastic than misused opioids, OMTs may not be without risk of disrupting the neural and molecular structures of the Maternal Brain Network. This review describes the Maternal Brain Network as a framework for understanding how pharmacological differences in exogenous opioid exposure can disrupt the onset and maintenance of the maternal brain and summarizes opioid and OMT (in particular buprenorphine) use in the context of pregnancy and maternal behavior. This review also highlights future directions for evaluating exogenous opioid effects on the Maternal Brain Network in the hopes of raising awareness for the impact of the opioid crisis not only on exposed infants, but also on mothers and subsequent mother-infant bonds.

The Effects of opioids on female fertility, pregnancy and the breastfeeding mother-infant dyad: A Review

Opioids cover a broad class of natural, synthetic and semi-synthetic drugs that act on opioid receptors to produce powerful analgesic effects. Rates of opioid use and opioid agonist maintenance treatment have increased substantially in recent years, particularly among women. Trends and outcomes of opioids use on fertility, pregnancy and breastfeeding, and longer-term child developmental outcomes have not been well-described. Here, we review the existing literature on the health effects of opioid use on female fertility, pregnancy, breastmilk and the exposed infant. We find that the current literature is primarily concentrated on the impact of opioid use in pregnancy and neonatal outcomes, with little exploration of effects on fertility. Studies are limited in number, some with small sample sizes, and many are hampered by methodological challenges related to confounding and other potential biases. Opioid use is becoming more prevalent due to environmental pressures such as COVID-19. More research is needed to better elucidate its effects on reproductive health among younger women and support the development of evidence-based recommendations for safe prescription practices and public health messaging.

Non-pharmacological care for opioid withdrawal in newborns

BACKGROUND

The prevalence of substance use, both prescribed and non-prescribed, is increasing in many areas of the world. Substance use by women of childbearing age contributes to increasing rates of neonatal abstinence syndrome (NAS). Neonatal opioid withdrawal syndrome (NOWS) is a newer term describing the subset of NAS related to opioid exposure. Non-pharmacological care is the first-line treatment for substance withdrawal in newborns. Despite the widespread use of non-pharmacological care to mitigate symptoms of NAS, there is not an established definition of, and standard for, non-pharmacological care practices in this population. Evaluation of safety and efficacy of non-pharmacological practices could provide clear guidance for clinical practice.

OBJECTIVES

To evaluate the safety and efficacy of non-pharmacological treatment of infants at risk for, or having symptoms consistent with, opioid withdrawal on the length of hospitalization and use of pharmacological treatment for symptom management. Comparison 1: in infants at risk for, or having early symptoms consistent with, opioid withdrawal, does non-pharmacological treatment reduce the length of hospitalization and use of pharmacological treatment? Comparison 2: in infants receiving pharmacological treatment for symptoms consistent with opioid withdrawal, does concurrent non-pharmacological treatment reduce duration of pharmacological treatment, maximum and cumulative doses of opioid medication, and length of hospitalization?

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search CENTRAL (2019, Issue 10); Ovid MEDLINE; and CINAHL on 11 October 2019. We also searched clinical trials databases and the reference lists of retrieved articles for randomized controlled trials (RCTs), quasi-RCTs, and cluster trials.

SELECTION CRITERIA

We included trials comparing single or bundled non-pharmacological interventions to no non-pharmacological treatment or different single or bundled non-pharmacological interventions. We assessed non-pharmacological interventions independently and in combination based on sufficient similarity in population, intervention, and comparison groups studied. We categorized non-pharmacological interventions as: modifying environmental stimulation, feeding practices, and support of the mother-infant dyad. We presented non-randomized studies identified in the search process narratively.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We used the GRADE approach to assess the certainty of evidence. Primary outcomes in infants at risk for, or having early symptoms consistent with, opioid withdrawal included length of hospitalization and pharmacological treatment with one or more doses of opioid or sedative medication. Primary outcomes in infants receiving opioid treatment for symptoms consistent with opioid withdrawal included length of hospitalization, length of pharmacological treatment with opioid or sedative medication, and maximum and cumulative doses of opioid medication.

MAIN RESULTS

We identified six RCTs (353 infants) in which infants at risk for, or having symptoms consistent with, opioid withdrawal participated between 1975 and 2018. We identified no RCTs in which infants receiving opioid treatment for symptoms consistent with opioid withdrawal participated. The certainty of evidence for all outcomes was very low to low. We also identified and excluded 34 non-randomized studies published between 2005 and 2018, including 29 in which infants at risk for, or having symptoms consistent with, opioid withdrawal participated and five in which infants receiving opioid treatment for symptoms consistent with opioid withdrawal participated. We identified seven preregistered interventional clinical trials that may qualify for inclusion at review update when complete. Of the six RCTs, four studies assessed modifying environmental stimulation in the form of a mechanical rocking bed, prone positioning, non-oscillating waterbed, or a low-stimulation nursery; one study assessed feeding practices (comparing 24 kcal/oz to 20 kcal/oz formula); and one study assessed support of the maternal-infant dyad (tailored breastfeeding support). There was no evidence of a difference in length of hospitalization in the one study that assessed modifying environmental stimulation (mean difference [MD) -1 day, 95% confidence interval [CI) -2.82 to 0.82; 30 infants; very low-certainty evidence) and the one study of support of the maternal-infant dyad (MD -8.9 days, 95% CI -19.84 to 2.04; 14 infants; very low-certainty evidence). No studies of feeding practices evaluated the length of hospitalization. There was no evidence of a difference in use of pharmacological treatment in three studies of modifying environmental stimulation (typical risk ratio [RR) 1.00, 95% CI 0.86 to 1.16; 92 infants; low-certainty evidence), one study of feeding practices (RR 0.92, 95% CI 0.63 to 1.33; 49 infants; very low-certainty evidence), and one study of support of the maternal-infant dyad (RR 0.50, 95% CI 0.13 to 1.90; 14 infants; very low-certainty evidence). Reported secondary outcomes included neonatal intensive care unit (NICU) admission, days to regain birth weight, and weight nadir. One study of support of the maternal-infant dyad reported NICU admission (RR 0.50, 95% CI 0.13 to 1.90; 14 infants; very low-certainty evidence). One study of feeding practices reported days to regain birth weight (MD 1.10 days, 95% CI 2.76 to 0.56; 46 infants; very low-certainty evidence). One study that assessed modifying environmental stimulation reported weight nadir (MD -0.28, 95% CI -1.15 to 0.59; 194 infants; very low-certainty evidence) and one study of feeding practices reported weight nadir (MD -0.8, 95% CI -2.24 to 0.64; 46 infants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

We are uncertain whether non-pharmacological care for opioid withdrawal in newborns affects important clinical outcomes including length of hospitalization and use of pharmacological treatment based on the six included studies. The outcomes identified for this review were of very low- to low-certainty evidence. Combined analysis was limited by heterogeneity in study design and intervention definitions as well as the number of studies. Many prespecified outcomes were not reported. Although caregivers are encouraged by experts to optimize non-pharmacological care for opioid withdrawal in newborns prior to initiating pharmacological care, we do not have sufficient evidence to inform specific clinical practices. Larger well-designed studies are needed to determine the effect of non-pharmacological care for opioid withdrawal in newborns.

A Review of Feeding Practices in Infants With Neonatal Abstinence Syndrome

BACKGROUND

There has been an increase in infants with neonatal abstinence syndrome (NAS) in neonatal intensive care units (NICUs) over the past several decades. Infants with NAS experience withdrawal as a result of the sudden termination at birth of substance exposure during pregnancy. A serious sign related to infants diagnosed with NAS is poor feeding. The prevalence of NAS urges researchers and clinicians to develop effective strategies and techniques to treat and manage the poor feeding of infants exposed to substances in utero.

PURPOSE

To synthesize current feeding methods and practices used for infants diagnosed with NAS.

METHODS/SEARCH STRATEGY

PubMed, CINAHL, and Scopus were searched for articles published within the last 20 years that focused on feeding practices or feeding schedules, were written in English, were peer-reviewed, and described human studies. The search terms utilized were "neonatal abstinence syndrome" OR "neonatal opioid withdrawal syndrome" AND "feeding."

FINDINGS/RESULTS

Three findings emerged regarding techniques and management of poor feeding in the NAS population. The findings included infants who received mother's own milk had decreased severity and later onset of clinical signs of withdrawal, demand feeding is recommended, and the infant's cues may be helpful to follow when feeding.

IMPLICATIONS FOR PRACTICE

Clinicians should encourage mother's own milk in this population unless contraindications are present. Caregivers and clinicians must be receptive to cues when feeding infants with NAS.

IMPLICATIONS FOR RESEARCH

Even with the clinical knowledge and experience that infants with NAS are difficult to feed, there is limited research assessing techniques and schedules that are effective in managing successful feeding. Future research should compare feeding schedules such as on-demand feeding versus regimented feeding schedules, as well as investigate techniques that mothers and nurses can utilize to encourage oral intake in this population.Video abstract available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=37.

Breastfeeding Decision-Making in an Addiction Trajectory: An Exploratory Grounded Theory Study

BACKGROUND AND PURPOSE

Globally, five million women are affected by opioid use disorder (OUD). Women with OUD are less likely to breastfeed than the general population, increasing risk of neonatal withdrawal. Theoretical frameworks related to breastfeeding did not address women with OUD. The purpose of this study was to develop a conceptual model to better understand breastfeeding disparities among this vulnerable population.

METHODS

A grounded theory study was conducted from August 2018 to March 2019 to investigate concepts likely to influence breastfeeding decisions in women with OUD. In-depth interviews were conducted in North Carolina with 10 women in recovery who breastfed, and their six identified support persons. Data were analyzed through iterative coding. This article focuses on maternal perspectives of breastfeeding informed by support persons.

RESULTS

The overarching theme was breastfeeding decision-making in an addiction trajectory. Two antecedent pathways led to the recovery-relapse cycle. This cycle involved seeking, initiating, and maintaining recovery with episodic relapse. Perceived stigma linked the recovery-relapse cycle with breastworks. Breastworks, an emergent concept, was characterized by learning and knowing, good intentions, and health-care provider sensitivity.

IMPLICATIONS FOR PRACTICE

This grounded theory model may inform clinicians in caring for women with OUD and support breastfeeding and newborn well-being. Strategies to address research and practice may include the development of a mobile application, having women in recovery on the health-care team, and incorporation of breastfeeding guidelines.

Factors Associated With the Need for Pharmacological Management of Neonatal Opioid Withdrawal Syndrome

BACKGROUND

Neonatal opioid withdrawal syndrome (NOWS) is a significant and growing health problem that affects more than 23,000 infants annually, with an estimated hospital cost of more than $720 million.

PURPOSE

The purpose of this study was to examine factors associated with the need to initiate medication for the treatment of NOWS.

METHODS

A retrospective review of medical records was conducted of 204 infants born to mothers who used opioids during pregnancy from April 2011 to September 2017. Associations between maternal, infant, and environmental factors and the need for neonatal pharmacological management were examined using χ, t tests, and regression analysis.

RESULTS

Of 204 neonates exposed to opioids prenatally, 121 (59%) developed symptoms of NOWS, requiring treatment with morphine. Neonates requiring morphine had significantly higher gestational ages (37.7 weeks vs 36.4 weeks; P < .001), and mothers were present at the neonate's bedside for a lower proportion of their total hospital stay (57% vs 74% of days; P < .001). Maternal factors associated with the need for neonatal medication treatment included the mother's reason for opioid use (P = .014), primary type of opioid used (P < .001), tobacco use (P = .023), and use of benzodiazepines (P = .003).

IMPLICATIONS FOR PRACTICE

This research provides information regarding the proportion of infants exposed to opioids prenatally who develop NOWS that requires treatment, as well as maternal, infant, and environmental factors associated with the need for neonatal medication use.

IMPLICATIONS FOR RESEARCH

Future research is needed to examine these relationships prospectively in a larger and more diverse sample.

Effects of Partially Hydrolyzed Formula on Severity and Outcomes of Neonatal Abstinence Syndrome

OBJECTIVE

This study compares the effect of partially hydrolyzed formula (PHF) and standard formula (SF) on the severity and short-term outcomes of neonatal abstinence syndrome (NAS).

STUDY DESIGN

We performed a retrospective chart review of 124 opioid-dependent mothers and their term or near-term infants. Infants were categorized according to the predominant type of formula consumed during the hospital stay. Finnegan's scale was used to assess symptoms of withdrawal.

RESULTS

A total of 110 infants met our inclusion criteria. Thirty-four (31%) infants were fed predominantly PHF, 60 (54%) infants were fed SF, and 16 (15%) infants were fed maternal breast milk. There was no difference between the infants in the PHF and SF groups with respect to requirement of morphine (MSO₄) therapy, maximum dose of MSO₄ used, duration of MSO₄ treatment or length of hospital stay after performing multivariate analyses to control for type of drug used by the mother, maternal smoking, regular prenatal care, inborn status, and maximum Finnegan score prior to MSO₄ treatment.

CONCLUSION

Use of PHF failed to impact short-term outcomes in infants treated for NAS including maximum MSO₄ dose, duration of MSO₄ treatment, and length of hospital stay. A prospective randomized controlled trial may be indicated to confirm this finding.

Outcome reporting in neonates experiencing withdrawal following opioid exposure in pregnancy: a systematic review

Background

Neonatal withdrawal secondary to in utero opioid exposure is a growing global concern stressing the psychosocial well-being of affected families and scarce hospital resources. In the ongoing search for the most effective treatment, randomized controlled trials are indispensable. Consistent outcome selection and measurement across randomized controlled trials enables synthesis of results, fostering the translation of research into practice. Currently, there is no core outcome set to standardize outcome selection, definition and reporting. This study identifies the outcomes currently reported in the literature for neonates experiencing withdrawal following opioid exposure during pregnancy.

Methods

A comprehensive literature search of MEDLINE, EMBASE and Cochrane Central was conducted to identify all primary research studies (randomized controlled trials, clinical trials, case-controlled studies, uncontrolled trials, observational cohort studies, clinical practice guidelines and case reports) reporting outcomes for interventions used to manage neonatal abstinence syndrome between July 2007 and July 2017. All “primary” and “secondary” neonatal outcomes were extracted by two independent reviewers and were assigned to one of OMERACT’s core areas of “pathophysiological manifestation”, “life impact”, “resource use”, “adverse events”, or “death”.

Results

Forty-seven primary research articles reporting 107 “primary” and 127 “secondary” outcomes were included. The most frequently reported outcomes were “duration of pharmacotherapy” (68% of studies, N = 32), “duration of hospital stay” (66% of studies, N = 31) and “withdrawal symptoms” (51% of studies, N = 24). The discrepancy between the number of times an outcome was reported and the number of articles was secondary to the use of composite outcomes. Frequently reported outcomes had heterogeneous definitions or were not defined by the study and were measured at different times. Outcomes reported in the literature to date were mainly assigned to the core areas “pathophysiologic manifestations” or “resource use”. No articles reported included parent or former patient involvement in outcome selections.

Conclusions

Inconsistent selection and definition of primary and secondary outcomes exists in the present literature of pharmacologic and nonpharmacologic interventions for managing opioid withdrawal in neonates. No studies involved parents in the process of outcome selection. These findings hinder evidence synthesis to generate clinically meaningful practice guidelines. The development of a specific core outcome set is imperative.

Breastfeeding Motivators and Barriers in Women Receiving Medications for Opioid Use Disorder

Background: Women with opioid use disorder (OUD) are encouraged to breastfeed, but have lower breastfeeding rates than the general population. Objective: We examined self-reported barriers and motivators for breastfeeding in women with OUD and the relationship between maternal/postnatal factors and breastfeeding noninitiation/discontinuation. Materials and Methods: A cross-sectional design was used; 40 women with OUD who were eligible to breastfeed were included. Information about breastfeeding initiation, duration, barriers/motivators, demographic characteristics, and self-efficacy was obtained through semi-structured interviews at 4-8 weeks postpartum. Wilcoxon rank sum or Fisher's exact test was used to examine the relationship between maternal/postnatal factors and never-initiated/discontinued breastfeeding. Results: Respondents were 29.3 ± 5.3 years old; most were prescribed buprenorphine (77.5%); and 36.8% of infants were treated for neonatal opioid withdrawal syndrome with methadone or morphine. Most (75.0%) participants initiated breastfeeding; 50.0% continued breastfeeding at 4-8 weeks. The most common motivators included infant health (100%) and bonding (45.0%). On average, women reported discontinuing breastfeeding at 3.3 ± 1.1 weeks postpartum. The most common barriers were concerns regarding transfer of medications or other substances to the infant (50.0%) and concerns about breast milk supply (35.0%). Mean self-efficacy scores were similar among those who continued versus never-initiated/discontinued breastfeeding (33.5 versus 33.0; p = 0.388). Neonatal intensive care unit admission was associated with never-initiated/discontinued breastfeeding (p = 0.047). Conclusion: Women with OUD share many similar motivators and barriers to breastfeeding with the general population. Unique concerns include infant exposure to medications or substances, even in those who are eligible to breastfeed, which should be addressed by targeted education for patients and providers.

Opioid Use in Pregnancy

PURPOSE OF REVIEW

Perinatal opioid use is a major public health problem and is associated with a number of deleterious maternal and fetal effects. We review recent evidence of perinatal outcomes and treatment of opioid use disorder (OUD) during pregnancy.

RECENT FINDINGS

Opioid exposure in pregnancy is associated with multiple obstetric and neonatal adverse outcomes, with the most common being neonatal opioid withdrawal syndrome (NOWS). Treatment with buprenorphine or methadone is associated with NOWS, but neither medication appears to have significant adverse effects on early childhood development. Buprenorphine appears to be superior to methadone in terms of incidence and severity of NOWS in exposed infants. The long-term effects of opioid exposure in utero have been inconclusive, but recent longitudinal studies point to potential differences in brain morphology that may increase vulnerability to future stressors. Maintenance therapy with methadone or buprenorphine remains the standard of care for pregnant women with OUD given its consistent superiority to placebo in terms of rates of illicit drug use and pregnancy outcomes. New non-pharmacologic management options for NOWS appear promising. Future research is needed to further evaluate the effects of opioid exposure in utero and determine the optimal delivery model for maintenance therapy.

A Hospital-Level Intervention to Improve Outcomes of Opioid Exposed Newborns

PURPOSE

The purpose of this quality improvement project was to determine if non-pharmacologic strategies such as a rooming-in approach to care for newborns at risk of developing neonatal abstinence syndrome (NAS) would reduce total length of stay (LOS) and reduce the need for pharmacologic treatment.

DESIGN AND METHODS

This was a quality improvement project utilizing a retrospective chart review. Records of newborns with in-utero methadone or buprenorphine exposure were reviewed who were born between January 2016-July 2017 and July 2017-August 2018 at Wellspan Health York Hospital. Starting in July 2017, newborns exposed to opioids who transitioned normally remained with their mothers for monitoring in the newborn nursery. Monitoring for withdrawal was continued on the pediatric floor after the mother's discharge from the post-partum floor.

RESULTS

The primary outcome of total LOS was reduced from 14 days to 10.1 days (p = 0.014). The total length of pharmacologic treatment decreased from 15.68 days to 9.71 days (p = 0.023).

CONCLUSIONS

A rooming-in approach to care including management on a pediatric floor can reduce total length of stay and the duration of pharmacologic treatment in newborns with NAS. Newborns with NAS can be safely managed in an inpatient pediatric floor.

PRACTICE IMPLICATIONS

Implementing a rooming-in approach to care of newborns at risk of developing NAS can improve outcomes through a decreased length of hospital stay and decreased duration of pharmacologic treatment. This approach improves access to critical care services by safely monitoring newborns with NAS on an inpatient pediatric floor.

Supporting breastfeeding for women on opioid maintenance therapy: a systematic review

OBJECTIVE

Despite evidence to support breastfeeding, rates remain low in women on opioid maintenance therapy (OMT). The goal of this review was to synthesize current knowledge regarding interventions to promote breastfeeding in women on OMT.

STUDY DESIGN

A systematic search of databases including PubMed, CINAHL, PsycINFO, Embase, Scopus, Web of Science, and the Cochrane database of systematic reviews was conducted. Key words included breastfeeding, lactation, opioid use disorder, and opioid maintenance therapy. Risk of bias was assessed by two reviewers.

RESULT

Four quasi-experimental studies met inclusion criteria. Improved rates of breastfeeding reached statistical significance in all four. Three studies had moderate to serious risk of bias related to confounding variables. Interventions shared common features, including an integrated approach, a well-prepared multidisciplinary team, nonseparation of mother and newborn, and patient centered care.

CONCLUSIONS

Further research should explore barriers and facilitators to breastfeeding in this vulnerable population.

Maternity Care for Pregnant Women with Opioid Use Disorder: A Review

Opioid misuse is a problem that is complex and widespread. Opioid misuse rates are rising across all US demographics, including among pregnant women. The opioid epidemic brings a unique set of challenges for maternity health care providers, ranging from ethical considerations to the complex health needs and risks for both woman and fetus. This article addresses care for pregnant women during the antepartum, intrapartum, and postpartum periods through the lens of the opioid epidemic, including screening and counseling, an interprofessional approach to prenatal care, legal considerations, and considerations for care during labor and birth and postpartum. Providers can be trained to identify at-risk women through the evidence-based process of Screening, Brief Intervention, and Referral to Treatment (SBIRT) and connect them with the appropriate care to optimize outcomes. Women at moderate risk of opioid use disorder can be engaged in a brief conversation with their provider to discuss risks and enhance motivation for healthy behaviors.  Women with risky opioid use can be given a warm referral to pharmacologic treatment programs, ideally comprehensive prenatal treatment programs where available (a warm referral is a term used when a provider, with the patient's permission, contacts another provider or another service him or herself rather than providing a phone number and referral number). Evidence regarding care for the pregnant woman with opioid use disorder and practical clinical recommendations are provided.

Breastfeeding in Women on Opioid Maintenance Therapy: A Review of Policy and Practice

INTRODUCTION

Opioid use is epidemic in the United States. Opioid use disorder (OUD) in pregnancy, as well as neonatal abstinence syndrome, has quadrupled in the last decade, and opioid maintenance therapy is recommended for pregnant women with OUD. Breastfeeding is an important means of improving outcomes for these vulnerable women and newborns. The purpose of this study was to review current policy on breastfeeding and opioid maintenance therapy, the rates of breastfeeding among women in this population, and facilitators and barriers to implementing policy recommendations.

METHODS

CINAHL, PubMed, the Cochrane Database of Systematic Reviews, Embase, and Web of Science were searched. Inclusion criteria included publication between 2013 and 2018, English language, human only, and original data (except for policy statements). Studies were excluded if they did not report original data and did not examine breastfeeding for women on opioid maintenance therapy.

RESULTS

Eight policy statements and 17 original research studies were identified that met the search criteria. All the policy statements support breastfeeding for women who are stable on opioid maintenance therapy and do not have HIV. Despite this, rates of breastfeeding among women receiving opioid maintenance therapy remain low compared with women in the general population. Results of qualitative research indicates that women on opioid maintenance therapy face numerous barriers to breastfeeding, including misinformation from health care professionals. Quantitative research has only begun to identify interventions to improve breastfeeding outcomes in this population. Research was conducted primarily with white women receiving care at urban health care centers.

DISCUSSION

Practice lags behind policy in terms of supporting breastfeeding in women receiving opioid maintenance therapy. There is a need for more research that includes African American and rural women on opioid maintenance therapy, as well as quantitative research that uses findings from qualitative research to identify the best possible interventions for improving breastfeeding outcomes for women on opioid maintenance therapy and their newborns. One significant need is for health care provider education regarding these policies as well as best practices for providing breastfeeding education and support to this population.

Occupational Therapy Management Strategies for Infants With Neonatal Abstinence Syndrome: Scoping Review

With opioid use in North America rising, there is a growing incidence of neonatal abstinence syndrome (NAS). Infants with NAS experience withdrawal signs that interfere with their occupational performance in activities of daily living. This scoping review aims to identify the non-pharmacologic interventions currently used in the treatment of infants with NAS that fall within the scope of the occupational therapy profession. Searching three databases, articles were independently reviewed by two authors to meet defined inclusion criteria. Forty-five articles were included, and the interventions identified and organized according to the Person-Environment-Occupation Model. The non-pharmacologic interventions identified fall within the scope of the occupational therapy profession. Initiating occupational therapy services in an acute care setting may have the potential to improve occupational performance and engagement for these infants from an early age.

Breastmilk feeding for mothers and infants with opioid exposure: What is best?

With rare exception, breastfeeding is the optimal way to feed infants, and has special benefits for women and infants with perinatal opioid exposure. Infants breastfed and/or fed their mother's own breastmilk experience less severe opioid withdrawal symptoms, have shorter hospital stays, and are less likely to be treated with medication for withdrawal. The specific impact of mothers' milk feeding on opioid withdrawal may be related to the act of breastfeeding and associated skin-to-skin contact, qualities of breastmilk, healthier microbiome, small amounts of opioid drug in breastmilk, or a combination of these. Women with opioid use disorder face significant breastfeeding obstacles, including psychosocial, behavioral, concomitant medications, and tobacco use and thus may require high levels of support to achieve their breastfeeding goals. They often don't receive information to make informed infant feeding decisions. Hospital practices such as prenatal education, rooming-in and having a policy that minimizes barriers to breastfeeding are associated with increased breastfeeding rates.

Breastfeeding Intention Compared With Breastfeeding Postpartum Among Women Receiving Medication-Assisted Treatment

BACKGROUND:

Women taking methadone or buprenorphine are encouraged to breastfeed if stable without polysubstance use.

RESEARCH AIM:

We aimed to determine the difference between stated intention to breastfeed prenatally in women taking methadone or buprenorphine compared with breastfeeding at discharge and 2 months postpartum. Secondary outcomes were determining whether breastfeeding was more common in women taking buprenorphine, in women without hepatitis C infection, and in women without a history of heroin use, and whether breastfeeding reduced the need for pharmacological treatment of neonatal opioid withdrawal syndrome.

METHODS:

This was a retrospective cohort study of 228 women enrolled in a perinatal substance abuse treatment program. Electronic medical records were reviewed to abstract data on mother-infant dyads. Chi-square tests were used to analyze our outcomes.

RESULTS:

Women taking buprenorphine had a higher prevalence of breastfeeding compared with women taking methadone (83% [ n = 100] vs. 71% [ n = 76]; χ² = 4.35, p = .03), despite no difference in their prenatal intention to breastfeed (87% vs. 81%; χ² = 1.28, p = .25). Only 31% ( n = 38) of women taking buprenorphine and 19.6% ( n = 21) of women taking methadone exclusively breastfed at discharge (χ² = 5.43, p = .06). Exclusively breastfed infants required less pharmacological treatment for neonatal opioid withdrawal syndrome compared with formula-fed infants (15.8% [ n = 21] vs. 47.4% [ n = 38]; χ² = 19.72, p < .05).

CONCLUSION:

Despite most women reporting a high prenatal intention to breastfeed, exclusive breastfeeding at hospital discharge postpartum was low. Breastfeeding was associated with a decreased likelihood of pharmacological treatment for neonatal opioid withdrawal syndrome.

Hepatitis C Virus Knowledge Among Pregnant Women with Opioid Use Disorder

Objectives To evaluate Hepatitis C virus (HCV) knowledge and awareness among pregnant women with opioid use disorder (OUD). Methods From May through November 2015, a one-time survey was distributed to a convenience sample of pregnant women with OUD to assess their knowledge and awareness of (a) risk factors for HCV infection, (b) HCV transmission prevention strategies, (c) hepatotoxic risk reduction and (d) perinatal transmission and neonatal implications of HCV infection. Chi square and Fisher's exact tests were used to compare demographic characteristics and HCV knowledge between participants who were HCV positive and negative. Results Of 179 pregnant women with OUD approached, 169 (94%) completed the survey. Of these, 153 (90.5%) reported at least one risk factor for HCV infection, 85 (50.3%) were HCV positive and 38 (44.7%) of HCV positive women were diagnosed with HCV for the first time during pregnancy. When HCV knowledge was evaluated, 114 (66.7%) responded that sharing eating utensils could transmit HCV, 69 (55.0%) responded that there is a vaccine to prevent HCV and 56 (32.7%) did not identify intranasal drug use as a risk factor for HCV transmission. Among HCV positive women, 61 (71.8%) associated breastfeeding with an increased risk for HCV transmission, 33 (38.1%) failed to identify the importance of pediatric follow-up for HCV-exposed children and 16 (18.8%) perceived the risk of HCV vertical transmission as "likely" or "very likely." Conclusions for Practice Gaps in HCV knowledge exist among a rapidly growing population of pregnant women with OUD. Healthcare providers have a unique opportunity to provide HCV education and counseling during pregnancy.

Examination of Hospital, Maternal, and Infant Characteristics Associated with Breastfeeding Initiation and Continuation Among Opioid-Exposed Mother-Infant Dyads

OBJECTIVES

Among opioid-exposed newborns, breastfeeding is associated with less severe withdrawal signs, yet breastfeeding rates remain low. We determined the extent to which hospital, maternal, and infant characteristics are associated with breastfeeding initiation and continuation among opioid-exposed dyads.

MATERIALS AND METHODS

We examined breastfeeding initiation and continuation until infants' discharge among opioid-exposed dyads from 2006 to 2016. Among dyads meeting hospital breastfeeding guidelines, we assessed hospital (changes in breastfeeding guidelines and improvement initiatives [using delivery year as a proxy]), maternal (demographics, comorbid conditions, methadone versus buprenorphine treatment, and delivery mode), and infant (gestational age and birth weight) characteristics. We used multivariable logistic regression to examine independent associations of characteristics with breastfeeding initiation and continuation.

RESULTS

Among 924 opioid-exposed dyads, 61% (564) met breastfeeding criteria. Overall, 50% (283/564) of dyads initiated and 33% (187/564) continued breastfeeding until discharge. Breastfeeding initiation and continuation rates increased from 38% and 8% in 2006, to 56% and 34% in 2016, respectively. In adjusted models, infants born after reducing restrictions in hospital breastfeeding guidelines and prenatal breastfeeding education (adjusted odds ratio, aOR 2.6 [95% confidence interval, CI 1.5-4.5]) had increased odds of receiving any maternal breast milk versus infants born with earlier hospital policies. Cesarean versus vaginal delivery (aOR 0.3 [95% CI 0.2-0.6]) and length of infant hospitalization (aOR 0.94 [95% CI 0.92-0.97]) were negatively associated with breastfeeding continuation.

CONCLUSIONS

Despite increasing breastfeeding rates among opioid-exposed dyads, rates remain suboptimal. Hospital-level factors were the greatest predictor of breastfeeding initiation. The findings suggest that changes in hospital guidelines and initiatives can impact breastfeeding initiation among this vulnerable population.

No. 349-Substance Use in Pregnancy

OBJECTIVES

To improve awareness and knowledge of problematic substance use in pregnancy and to provide evidence-based recommendations for the management of this challenging clinical issue for all health care providers.

OPTIONS

This guideline reviews the use of screening tools, general approach to care, and recommendations for the clinical management of problematic substance use in pregnancy.

OUTCOMES

Evidence-based recommendations for screening and management of problematic substance use during pregnancy and lactation.

EVIDENCE

Updates in the literature were retrieved through searches of Medline, PubMed, and The Cochrane Library published from 1996 to 2016 using the following key words: pregnancy, electronic cigarettes, tobacco use cessation products, buprenorphine, and methadone. Results were initially restricted to systematic reviews and RCTs/controlled clinical trials. A subsequent search for observational studies was also conducted because there are few RCTs in this field of study. Articles were restricted to human studies published in English. Additional articles were located by hand searching through article reference lists.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described in that report.

BENEFITS, HARMS, AND COSTS

This guideline is intended to increase the knowledge and comfort level of health care providers caring for pregnant women who have substance use disorders. Improved access to health care and assistance with appropriate addiction care lead to reduced health care costs and decreased maternal and neonatal morbidity and mortality.

RECOMMENDATIONS

Opioid Use Disorders and Pregnancy

Opioid use disorder presents an increased risk of complications in pregnancy, particularly when untreated. To optimize outcomes, medication-assisted treatment using methadone or buprenorphine as a part of a comprehensive care model is recommended. Neonatal abstinence syndrome and poor fetal growth remain significant complications of this disorder despite maternal treatment.

No 349 - Consommation de substances psychoactives pendant la grossesse

OBJECTIFS

Accroître la sensibilisation à la consommation problématique de substances psychoactives pendant la grossesse et les connaissances à ce sujet, et formuler des recommandations factuelles relatives à la prise en charge de cet épineux problème clinique à l'intention de l'ensemble des fournisseurs de soins.

OPTIONS

La présente directive clinique analyse l'utilisation d'outils de dépistage, l'approche générale de soins et les recommandations pour la prise en charge clinique de la consommation problématique de substances psychoactives pendant la grossesse.

ISSUES

Recommandations factuelles pour le dépistage et la prise en charge de la consommation problématique de substances psychoactives pendant la grossesse et l'allaitement.

RECHERCHE DOCUMENTAIRE

La littérature à jour a été obtenue au moyen de recherches dans Medline, PubMed et la Bibliothèque Cochrane visant les articles publiés entre 1996 et 2016, avec les mots clés suivants : « pregnancy », « electronic cigarettes », « tobacco use cessation products », « buprenorphine » et « methadone ». Les résultats ont d'abord été restreints aux analyses systématiques, aux ECR et aux essais cliniques contrôlés. Ensuite, en raison de la rareté des ECR sur le sujet, des recherches d'études observationnelles ont également été menées. Les articles sélectionnés ont été limités aux études chez l'humain publiées en anglais, puis d'autres articles ont été trouvés manuellement, par l'analyse des listes de références.

VALEURS

La qualité des données a été évaluée au moyen des critères énoncés dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs. Les recommandations visant la pratique ont été classées conformément à la méthode décrite dans ce rapport. AVANTAGES, DéSAVANTAGES ET COûTS: La présente directive clinique a pour but d'améliorer les connaissances et le degré d'aisance des fournisseurs qui dispensent des soins aux femmes enceintes ayant un trouble de l'usage d'une substance. L'amélioration de l'accès aux soins de santé et de l'aide pour obtenir un traitement adéquat de la dépendance fait diminuer les coûts de santé et les taux de morbidité et de mortalité chez la mère et l'enfant. RECOMMANDATIONS.

Opioid Use in Pregnancy, Neonatal Abstinence Syndrome, and Childhood Outcomes: Executive Summary of a Joint Workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, American College of Obstetricians and Gynecologists, American Academy of Pediatrics, Society for Maternal-Fetal Medicine, Centers for Disease Control and Prevention, and the March of Dimes Foundation

In April 2016, the Eunice Kennedy Shriver National Institute of Child Health and Human Development invited experts to a workshop to address numerous knowledge gaps and to review the evidence for the screening and management of opioid use in pregnancy and neonatal abstinence syndrome. The rising prevalence of opioid use in pregnancy has led to a concomitant dramatic fivefold increase in neonatal abstinence syndrome over the past decade. Experts from diverse disciplines addressed research gaps in the following areas: 1) optimal screening for opioid use in pregnancy; 2) complications of pregnancy associated with opioid use; 3) appropriate treatments for pregnant women with opioid use disorders; 4) the best approaches for detecting, treating, and managing newborns with neonatal abstinence syndrome; and 5) the long-term effects of prenatal opioid exposure on children. Workshop participants identified key scientific opportunities to advance the understanding of opioid use disorders in pregnancy and to improve outcomes for affected women, their children, and their families. This article provides a summary of the workshop presentations and discussions.

Does Breast Milk Affect Neonatal Abstinence Syndrome Severity, the Need for Pharmacologic Therapy, and Length of Stay for Infants of Mothers on Opioid Maintenance Therapy During Pregnancy?

BACKGROUND

The United States is in an opioid crisis with abuse among women on the rise over the past 10 years. Infants of opioid-dependent mothers are at risk for neonatal abstinence syndrome (NAS). Neonatal abstinence syndrome can affect multiple systems and disrupt normal growth and development. It is for this reason that strategies to promote health such as breastfeeding need to be explored. This brief evaluates current evidence regarding breast milk and the impact it has on NAS.

PURPOSE

The question guiding this brief is: "Does provision of breast milk reduce NAS withdrawal symptoms, decrease length of stay, and decrease the need for pharmacologic therapy for infants whose mothers are maintained on methadone or buprenorphine?"

SEARCH STRATEGY

CINHAL/MEDLINE Complete and PubMed databases were searched using key words-NAS and breastfeeding-and the search was limited to 10 years for English studies evaluating the effects of breast milk on severity of NAS, pharmacologic therapy, and length of stay whose mothers received methadone or buprenorphine during pregnancy. The search yielded 10 studies addressing these concerns.

FINDINGS

Breast milk may be beneficial for decreasing NAS severity, pharmacologic therapy, and length of stay.

IMPLICATIONS FOR PRACTICE

Strategies should be developed to support individualized plans based on maternal history, safety, and mother's choice.

IMPLICATIONS FOR RESEARCH

Further research is needed utilizing matched case-controlled studies regarding breast milk and the influence on severity of NAS, need for pharmacologic therapy, length of stay, and neurologic outcomes. In addition, other factors should be investigated including abrupt weaning, polysubstance use, and readmissions.

Breastfeeding among Mothers on Opioid Maintenance Treatment: A Literature Review

Although there is an abundance of interventional studies to increase breastfeeding rates, little is known about how to support and promote breastfeeding among mothers on opioid maintenance treatment (OMT). The studies on maternal OMT mainly focus on medication excreted in breast milk and breastfeeding benefits for infants with neonatal abstinence syndrome (NAS). We aim to review interventions to improve breastfeeding outcomes among mothers on OMT to make recommendations for practice and future research. We searched CINAHL, PubMed, PsycINFO, and the Cochrane Database of Systematic Reviews for articles, preferably experimental/quasi-experimental studies published within the past 10 years, that examined interventions to increase rates of breastfeeding initiation and duration among mothers on OMT. Nine studies met our inclusion criteria, comprising 5 categories: 4 combined obstetric and addiction care, 1 rooming-in, 1 Baby-Friendly hospital, 2 inpatient/outpatient NAS treatment, and 1 divided methadone dose. Breastfeeding rates were relatively higher for divided methadone dose (81% initiated any breastfeeding) and rooming-in (62% initiated any breastfeeding); lower in Baby-Friendly hospital (24%) and inpatient/outpatient NAS treatment (45% and 24%, respectively); and mixed in combined obstetric and addiction care programs (2 studies reported 70% and 76%; 2 studies reported 17% and 28%). Studies that included both methadone and buprenorphine did not specify breastfeeding results by medication. We recommend future research to differentiate breastfeeding types and duration by OMT medication. Qualitative studies are needed to explore maternal view on breastfeeding regarding need, barrier, and motivating factors in order to develop effective interventions to promote breastfeeding among mothers on OMT.

Breastfeeding and Opiate Substitution Therapy: Starting to Understand Infant Feeding Choices

INTRODUCTION

Despite research demonstrating the safety and benefit of breastfeeding in opioid substitution therapy, few women in treatment breastfeed. Understanding the factors contributing to the choices women on opioid substitution therapy make about infant feeding is important.

OBJECTIVES

The aim of this study was to better understand and support infant feeding choices and breastfeeding experiences in women on opioid substitution therapy.

METHODS

A systematic review was conducted on five databases: (1) Ovid MEDLINE(R) without revisions, (2) Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, (3) EMBASE, (4) CINAHL, and (5) FRANCIS. From 1081 articles, 46 articles were reviewed.

RESULTS

The literature supports breastfeeding as an appropriate and safe option for women on opioid substitution treatment. Breastfeeding and rooming-in reduce neonatal abstinence. Women face barriers to breastfeeding due to societal stigma and the lack of patient and health-care provider education.

CONCLUSIONS

Efforts are needed to increase the knowledge that women and health-care professionals have about the safety and benefits of breastfeeding.

Caring for Pregnant Women with Opioid Use Disorder in the USA: Expanding and Improving Treatment

PURPOSE OF THE REVIEW

Opioid use disorder in the USA is rising at an alarming rate, particularly among women of childbearing age. Pregnant women with opioid use disorder face numerous barriers to care, including limited access to treatment, stigma, and fear of legal consequences. This review of opioid use disorder in pregnancy is designed to assist health care providers caring for pregnant and postpartum women with the goal of expanding evidence-based treatment practices for this vulnerable population.

RECENT FINDINGS

We review current literature on opioid use disorder among US women, existing legislation surrounding substance use in pregnancy, and available treatment options for pregnant women with opioid use disorder. Opioid agonist treatment (OAT) remains the standard of care for treating opioid use disorder in pregnancy. Medically assisted opioid withdrawal ("detoxification") is not recommended in pregnancy and is associated with high maternal relapse rates. Extended release naltrexone may confer benefit for carefully selected patients. Histories of trauma and mental health disorders are prevalent in this population; and best practice recommendations incorporate gender-specific, trauma-informed, mental health services. Breastfeeding with OAT is safe and beneficial for the mother-infant dyad.

SUMMARY

Further research investigating options of OAT and the efficacy of opioid antagonists in pregnancy is needed. The US health care system can adapt to provide quality care for these mother-infant dyads by expanding comprehensive treatment services and improving access to care.

Substance use during pregnancy

Prenatal substance use is a critical public health concern that is linked with several harmful maternal and fetal consequences. The most frequently used substance in pregnancy is tobacco, followed by alcohol, cannabis and other illicit substances. Unfortunately, polysubstance use in pregnancy is common, as well as psychiatric comorbidity, environmental stressors, and limited and disrupted parental care, all of which can compound deleterious maternal and fetal outcomes. There are few existing treatments for prenatal substance use and these mainly comprise behavioral and psychosocial interventions. Contingency management has been shown to be the most efficacious of these. The purpose of this review is to examine the recent literature on the prenatal use of tobacco, alcohol, cannabis, stimulants, and opioids, including the effects of these on maternal and fetal health and the current therapeutic options.

Revision of Breastfeeding Guidelines in the Setting of Maternal Opioid Use Disorder: One Institution's Experience

Breastfeeding is recommended for women with opioid use disorder who are treated with methadone or buprenorphine. Infants with neonatal abstinence syndrome (NAS) secondary to in-utero opioid exposure have unique challenges related to breastfeeding but also have significant benefits including improved NAS symptoms with a decreased need for pharmacotherapy. Poor understanding of substance use disorder and treatment, lack of evidence-based recommendations, and vague guidelines from national academies create controversy about breastfeeding eligibility for these women. Defining breastfeeding guidelines is often difficult, particularly in large institutions with multiple providers caring for the mother-infant dyad. Based on the available evidence and review of our institutional data, we revised our breastfeeding guidelines for mothers with opioid use disorder. The aims of our new guidelines are (a) to safely promote breastfeeding in all mothers with opioid use disorder who are in recovery, (b) to improve NAS outcomes through use of breastfeeding as a key nonpharmacologic treatment modality, and (c) to improve staff communication and consistency on the subject of breastfeeding in this patient population.

Failure to initiate breastfeeding among high risk obstetrical patients who intended to breastfeed

BACKGROUND

In the US, at the time of discharge from the hospital, 79% of women had initiated breastfeeding. Intention to breastfeed is a strong predictor of breastfeeding initiation; however, we reported initiation failure in 45% of women with pregestational diabetes who intended to breastfeed. Information regarding intention and initiation among women with other high risk obstetrical conditions (HROB) remains scarce.

OBJECTIVE

To ascertain demographic and clinical factors associated with breastfeeding initiation failure among women with HROB conditions who intended to breastfeed.

METHODS

The study population is comprised of 89 women with diabetes (DM), 57 who were receiving treatment for substance abuse (SA), 51 women diagnosed with miscellaneous (MISC) conditions and 32 with history of preterm labor/delivery (PTL/D). Intention to exclusively breastfeed or in combination with formula (breastfed/FF) was ascertained prenatally. Breastfeeding was considered initiated if at discharge ≥50% of their infant feedings were maternal milk. Statistics include chi-square, Wilcoxon's and logistic regression (p < 0.05).

RESULTS

Of all women, 59% initiated any breastfeeding. Intention to breastfeed/FF, lack of mother-infant contact during the first hour following birth and limited lactation consultation were predictive of initiation failure. The odds of initiation failure were 2.3 times higher among women who wished to breastfeed/FF as compared to those who wished to exclusively breastfeed. Women from the SA group had lower rates of initiation failure than the other three HROB groups.

CONCLUSION

Intention to breastfeed among women with diverse HROB conditions is similar to that of the general population; however, initiation rates are disappointingly low. Intention to exclusively breastfeed results in fewer initiation failures. Prenatal intention to combine breast and formula feeding characterize women who may benefit from specific educational programs.