Breastfeeding among Mothers on Opioid Maintenance Treatment: A Literature Review

The Impact of a Multidisciplinary Opioid Use Disorder Prenatal Clinic on Breastfeeding Rates and Postpartum Care

OBJECTIVE

To evaluate the hypothesis that patients with opioid use disorder (OUD), who receive prenatal care in a multidisciplinary, prenatal OUD clinic, have comparable postpartum breastfeeding rates, prenatal and postpartum visit compliance, and postpartum contraceptive use when compared with matched controls without a diagnosis of OUD.

STUDY DESIGN

This was a retrospective, matched, cohort study that included all patients who received prenatal care in a multidisciplinary, prenatal OUD clinic-Clinic for Acceptance Recovery and Empowerment (CARE)-between September 2018 and August 2020. These patients were maintained on opioid agonist therapy (OAT) throughout their pregnancy. CARE patients were matched to controls without OUD in a 1:4 ratio for mode of delivery, race, gestational age ± 1 week, and delivery date ± 6 months. The primary outcome was rate of exclusive breastfeeding at maternal discharge. Secondary outcomes included adherence with prenatal care (≥4 prenatal visits), adherence with postpartum care (≥1 postpartum visit), postpartum contraception plan prior to delivery, and type of postpartum contraceptive use. Conditional multivariate logistic regression was used to account for possible confounders in adjusted calculations.

RESULTS

A total of 210 patients were included (42 CARE and 168 matched controls). Despite having lower rates of adequate prenatal care, 40 CARE patients (95%) were exclusively breastfeeding at discharge resulting in CARE patients being significantly more likely to be breastfeeding at discharge (adjusted relative risk (aRR): 1.28, 95% confidence interval [CI]: 1.05-1.55). CARE patients and controls demonstrated no difference in postpartum visit compliance (86 vs. 81%, aRR: 1.03, 95% CI: 0.76-1.40) or effective, long-term contraception use (48 vs. 48%; aRR: 0.81, 95% CI: 0.36-1.84).

CONCLUSION

In the setting of multidisciplinary OUD prenatal care during pregnancy, patients with OUD were more likely to be breastfeeding at the time of discharge than matched controls, with no difference in postpartum visit compliance or effective, long-term contraception.

KEY POINTS

· Women with OUD are more likely to breastfeed when engaged in a multidisciplinary prenatal clinic.. · Women with OUD had no difference in LARC use when engaged in a multidisciplinary prenatal clinic.. · Women with OUD had no difference in postpartum visit rate in a multidisciplinary prenatal clinic..

Group prenatal care for pregnant women with opioid use disorder: Preliminary evidence for acceptability and benefits compared with individual prenatal care

INTRODUCTION

The effectiveness of group prenatal care (G-PNC) compared with individual prenatal care (I-PNC) for women with opioid use disorder (OUD) is unknown. The objectives of this study were to (1) assess the acceptability of co-locating G-PNC at an opioid treatment program and (2) describe the maternal and infant characteristics and outcomes of pregnant women in treatment for OUD who participated in G-PNC and those who did not.

METHODS

This was a retrospective cohort study of 71 women (G-PNC n = 15; I-PNC n = 56) who were receiving treatment for OUD from one center and who delivered in 2019. Acceptability was determined by assessing the representativeness of the G-PNC cohorts, examining attendance at sessions, and using responses to a survey completed by G-PNC participants. The receipt of health services and healthcare use, behaviors, and infant health between those who participated in G-PNC and those who received I-PNC were described.

RESULTS

G-PNC was successfully implemented among women with varying backgrounds (e.g., racial, ethnic, marital status) who self-selected into the group. All G-PNC participants reported that they were satisfied to very satisfied with the program. Increased rates of breastfeeding initiation, breastfeeding at hospital discharge, receipt of the Tdap vaccine, and postpartum visit attendance at 1-2 weeks and 4-8 weeks were observed in the G-PNC group compared with the I-PNC group. Fewer G-PNC reported postpartum depression symptomatology.

CONCLUSION

Findings suggest that co-located G-PNC at an opioid treatment program is an acceptable model for pregnant women in treatment for OUD and may result in improved outcomes.

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.

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.

Gender Dynamics in Substance Use and Treatment: A Women's Focused Approach

Gender impacts substance use initiation, substance use disorder development, engagement with treatment, and harms related to drug and alcohol use. Using the biopsychosocial model of addiction, this review provides a broad summary of barriers and facilitators to addiction services among women. It also reviews substance use among pregnant and parenting women and approaches to care. Given the increasing rates of substance use among women, there is a need to implement and scale-up gender-responsive addiction programming and pursue advocacy at the policy level that addresses the root drivers of substance use inequities among women.

Neurotoxic effect of nalufin on the histology, ultrastructure, cell cycle and apoptosis of the developing chick embryo and its amelioration by selenium

The use of opioids during pregnancy has recently dramatically increased presenting major health problems, especially on the developing neonatal nervous system development. Nalufin is considered one of the most used opioid analgesics for treatment of moderate to severe pain, especially during pregnancy. The aim of the present study was firstly to assess the possible neurotoxic effects of nalufin injection during the organogenesis period of chick embryos, and second to investigate the ameliorative effects of selenium as a supplement. Fertilized chicken eggs were in ovo injected with 0.2ml of either nalufin (20 mg/kg egg) or selenium (0.1 mg/kg egg) or both. Nalufin injection resulted in cerebral cortical layer disruption, increase of Caspase-3 immunoexpression and chromatolytic nuclei, degenerated organelles, rarefied cytoplasm and hemorrhage. On the molecular levels, nalufin induced DNA fragmentation, cell cycle arrest and increased the percentage of apoptosis of the neuronal cells. Selenium combined treatment restored the three-layered structure of the cerebral cortex, decreased caspase-3 immuno-expression, improved ultrastructure and recovered cell cycle arrest, decreased apoptosis, and DNA degradation. In conclusion, nalufin treatment during pregnancy imposes great concerns and should not be used during embryonic development, on the other hands, selenium appears to be a promising neuroprotective agent against nalufin-induced neurotoxicity.

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.

Integrating reproductive health care into substance use disorder services

People who use drugs face layered stigma and barriers to accessing reproductive health care services. At the same time, they have unique needs for compassionate, trauma-informed, low-barrier reproductive health care. We review the literature on collocated reproductive health care and substance use treatment services in this population and advocate for expansion of reproductive health care services at sites providing care for substance use disorder. Through this review article, we outline the evidence for and best practices in collocating reproductive health care within substance use disorder services.

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.

Executive Summary of the Focused Update of the ASAM National Practice Guideline for the Treatment of Opioid Use Disorder

: A Focused Update of the ASAM National Practice Guideline for the Treatment of Opioid Use Disorder is published in the current issue of the Journal of Addiction Medicine. The focused update included a search of Medline's PubMed database from January 1, 2014 to September 27, 2018, as well as a search of the grey literature (archives of the Clinical Guideline Clearinghouse, and key agency and society websites) for new practice guidelines and relevant systematic reviews addressing the use of medications and psychosocial treatments in the treatment of opioid use disorder, including within special populations. The search identified 11 practice guidelines and 35 systematic reviews that informed the subsequent RAND/UCLA Appropriateness Method (RAM) process employed to facilitate the focused update by a National Guideline Committee of addiction experts. New and updated recommendations were included if they were considered: (a) clinically meaningful and applicable to a broad range of clinicians treating addiction involving opioid use; and (b) urgently needed to ensure the Practice Guideline reflects the current state of the science for the existing recommendations, aligns with other relevant practice guidelines, and reflects newly approved medications and formulations.

Australian Foster Carers' Views and Concerns Regarding Maternal Drug Use and the Safety of Breastmilk

Parental substance misuse and mental health issues are major factors associated with infant placement into out-of-home care. Such placements may result in disruption and/or cessation of breastfeeding. Provision of breastmilk to infants in out-of-home care (OOHC) is desirable in terms of infant health and development, and also in supporting maternal caregiving. However, little is known about how breastfeeding is supported for infants in out-of-home care. This study used an online survey to explore the facilitation of breastfeeding in the context of OOHC and foster carers' management of expressed breastmilk (EBM). Foster carers were generally open to the idea of maternal breastfeeding and infants in their care receiving EBM from their mothers. However, the majority of respondents expressed concern regarding the safety of EBM for infant consumption due to the possibility of harmful substances in the milk. Concerns regarding the safety of handling EBM were also prevalent. These concerns caused foster carers to discard EBM. Findings suggest foster carers' may lack knowledge related to maternal substance use and breastmilk. Better integration between health care and social service systems, where the voices of mothers, foster carers and child protection workers are heard, is necessary to develop solutions enabling infants living in OOHC access to their mother's breastmilk.

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 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.

Neonatal Abstinence Syndrome: Review of Epidemiology, Care Models, and Current Understanding of Outcomes

The incidence of neonatal abstinence syndrome owing to prenatal opioid exposure has grown rapidly in recent decades and it disproportionately affects rural, non-white, and public insurance-dependent populations. Treatment consists of pharmacologic and nonpharmacologic interventions with wide variability in approaches across the United States. Standardizing clinical assessment, minimizing unnecessary interruptions, and prioritizing nonpharmacologic and family-centered care seems to improve hospital outcomes. Neonatal abstinence syndrome may have long-term developmental and biological effects, but understanding is limited owing in part confounding biosocial factors. Early intervention and longitudinal support of the infant and family promote better outcomes.

Exposures Through Breast Milk: An Analysis of Exposure and Information Calls to U.S. Poison Centers, 2001-2017

Introduction: We described calls to U.S. poison centers (PCs) related to potential exposure to substances through breast milk. Materials and Methods: We analyzed National Poison Data System calls between 2001 and 2017 with "Exposure through breast milk" or "Drug use during breastfeeding" as the coded scenario. Data handling and descriptive statistics were carried out using SAS JMP 12.01. Results: U.S. PCs received 76,416 information calls and 2,319 exposure calls related to breast milk. Exposure calls were from a residence in 76% (n = 1,758), from health care facilities (HCFs) in 15.5% (n = 360), and from a workplace in 0.6% (n = 15). A total of 466 exposures (20.1%) were subsequently managed at a HCF: 269 were evaluated and released (58%), 38 were admitted to intensive care unit (8.2%), and 53 were admitted to hospital floor (11%). Medical outcomes included 1 death (0.04%), 8 major effect (0.3%), 43 moderate effect (1.9%), 170 minor effect (7.3%), and 390 no effect (16.8%). Exposure calls that reported major effects involved opioids, benzodiazepines, ethanol, cyclobenzaprine, insulin, and amphetamines. Exposure calls most commonly involved antibiotics, antifungals, benzodiazepines, opioids, and selective serotonin reuptake inhibitors (SSRIs). A total of 1,192 exposures (51.4%) had reported signs/symptoms including drowsiness, agitation, rash, and vomiting/diarrhea. Information calls most commonly involved systemic antibiotics, SSRIs, antihistamines, corticosteroids, and benzodiazepines. Conclusions: Substances common to both exposure and information calls included antibiotics, benzodiazepines, and SSRIs. Most cases of severe toxicity included potential exposures through breast milk to benzodiazepines and opioids. These data may help inform educational outreach, risk assessment, and bedside care for breastfeeding mothers.

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.

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.

Analgesia, Opioids, and Other Drug Use During Pregnancy and Neonatal Abstinence Syndrome

When opioid misuse rises in the United States, pregnant women and their neonates are affected. This article summarizes the use of Food and Drug Administration-approved products, including methadone, buprenorphine, and the combination formulation of buprenorphine and naloxone to treat adult opioid use disorder during the perinatal period. All labels include pregnancy, neonatal, and lactation information and note the accepted use of these medications during the perinatal period if the benefits outweigh the risks. A summary of the neonatal abstinence syndrome definition, its assessment tools, treatment approaches, and future genetic directions are provided.

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.

Outpatient pharmacologic weaning for neonatal abstinence syndrome: a systematic review

Aim

The purpose of this systematic review was to assess the literature regarding the effectiveness and safety of outpatient pharmacologic weaning for infants with neonatal abstinence syndrome (NAS).

Background

NAS is a multi-system disorder observed in infants experiencing withdrawal from opioid exposure in utero. Infants requiring pharmacologic treatment to manage withdrawal, traditionally receive treatment as a hospital inpatient resulting in lengthy hospitalization periods. However, there is evidence to suggest that some healthcare institutions are continuing outpatient pharmacologic weaning for select infants in a home environment. As there is no standard of care to guide outpatient weaning, assessment of the safety and effectiveness of this approach is warranted.

Method

A systematic review of outpatient weaning for infants with NAS was conducted using the electronic databases PubMed, Nursing and Allied Health, CINAHL, Evidence-Based Medicine, Web of Science, Medline, and PsychINFO. Studies were eligible for inclusion in the review if they fulfilled the following criteria: (1) reported original data on outcomes related to the effectiveness or safety of outpatient weaning for infants with NAS, (2) infants were discharged from hospital primarily receiving opioid pharmacologic treatment for NAS, (3) the method included quantitative designs that included an inpatient comparison group, and (4) articles were published in English in a peer-reviewed journal.

Findings

The search identified 154 studies, of which 18 provided information related to NAS and outpatient weaning. After reviewing the remaining full-text studies, six studies met all inclusion and exclusion criteria. All studies identified that outpatient weaning for select infants was associated with shorter hospitalization compared with infants weaned in-hospital only and may be potentially effective in reducing associated healthcare costs. However, duration of pharmacologic treatment was longer in the outpatient weaning groups in the majority of the studies. Furthermore, adverse events were rare and compliance to follow-up treatment was high among those who received outpatient weaning.

Opioid Use Dependency in the Mother Who Desires to Breastfeed Her Newborn: A Case Study

The number of infants born to mothers with opioid dependence is increasing at an alarming rate, indicating a 5-fold increase for women using opiates and a 3-fold increase in infants born with neonatal abstinence syndrome (NAS; Tsai & Doan, 2016 ). Pediatric Nurse Practitioners providing primary care, who lack experience with this clinical presentation, require evidence-based knowledge to provide the appropriate care to infants born with neonatal abstinence syndrome. Mothers with opioid dependence often desire to breastfeed their newborns, and the PNP may unknowingly discourage them from breastfeeding. In this case discussion, we describe how breastfeeding is possible and is beneficial. Current evidence-based practice recommendations and resources are included demonstrating that human breast milk has the potential to substantially improve health outcomes for all mothers and their newborns, especially this unique dyad (Tsai & Doan, 2016; Reece-Stremtan & Marinelli, 2015).

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.

Neonatal Abstinence Syndrome: Exploring Nurses' Attitudes, Knowledge, and Practice

BACKGROUND

As opioid abuse increases in the United States, the rate of neonatal abstinence syndrome (NAS) rises dramatically. Caring for infants with NAS and their families is a significant challenge to neonatal nurses.

PURPOSE

The purpose of this survey study was to explore attitudes and practice trends among nurses caring for infants with NAS. The study also aimed to identify any gaps in knowledge about NAS.

METHOD

An anonymous, cross-sectional survey study was conducted using a researcher-developed questionnaire. The survey questionnaire included 20 Likert-scale questions regarding nurses' attitudes, knowledge, and practice in care of infants with NAS, 1 case study with 3 questions, and 2 open-ended questions. Nurses, including advanced practice nurses and nurse leaders, were invited to participate at a regional neonatal nursing conference in the New England area.

RESULTS

A total of 54 participants responded, the majority being white, female, non-Hispanic, and bachelor's prepared. Many nurses shared concerns regarding the setting in which infants with NAS are cared for. Nurses expressed varying attitudes regarding interacting with the mothers but generally wanted to build a partnership with them. Nurses also reported a lack of standardized and consistent practice in care for infants with NAS. Three major themes were identified from open-ended questions, including environmental issues, relationship with the mother, and inconsistency in care.

IMPLICATIONS FOR PRACTICE

Further research is needed for nurses providing care to infants with NAS. Specific education programs are needed for nurses who are caring for infants with NAS.

IMPLICATIONS FOR RESEARCH

Further research is needed regarding the effects of NAS on nurses and other healthcare providers.

The Epidemic of Neonatal Abstinence Syndrome, Historical References of Its' Origins, Assessment, and Management

Neonatal abstinence syndrome (NAS) refers to a constellation of signs that are present in some newborn infants resulting from the abrupt cessation of passive transfer of maternal opioids used during pregnancy. The classic NAS refers to infants born to mothers who used opioids during pregnancy, but the term has broadened to include infants whose mothers have used or abused other psychoactive substances during pregnancy that contribute to the expression of the syndrome. Pregnant women who use opioids do so illicitly, and/or as medically prescribed for pain relief, and/or as medication assisted treatment for opioid dependence. The first case of NAS in infants and the subsequent treatment (or lack thereof) was reported in 1875 and was called Congenital Morphinism. By 2012, the incidence of NAS increased to more than 30 per 1,000 hospital live births, along with an increase in the number of infants being treated pharmacologically for NAS, resulting in an increase in the length of stay and healthcare expenses. We present historical references on NAS, the various factors and events that led to its increasing prevalence and today's current epidemic. We also review the current tools to assess infants with NAS and treatment options in its management.

Treating Women Who Are Pregnant and Parenting for Opioid Use Disorder and the Concurrent Care of Their Infants and Children: Literature Review to Support National Guidance

OBJECTIVES

The prevalence of opioid use disorder (OUD) during pregnancy is increasing. Practical recommendations will help providers treat pregnant women with OUD and reduce potentially negative health consequences for mother, fetus, and child. This article summarizes the literature review conducted using the RAND/University of California, Los Angeles Appropriateness Method project completed by the US Department of Health and Human Services Substance Abuse and Mental Health Services Administration to obtain current evidence on treatment approaches for pregnant and parenting women with OUD and their infants and children.

METHODS

Three separate search methods were employed to identify peer-reviewed journal articles providing evidence on treatment methods for women with OUD who are pregnant or parenting, and for their children. Identified articles were reviewed for inclusion per study guidelines and relevant information was abstracted and summarized.

RESULTS

Of the 1697 articles identified, 75 were included in the literature review. The perinatal use of medication for addiction treatment (MAT, also known as medication-assisted treatment), either methadone or buprenorphine, within comprehensive treatment is the most accepted clinical practice, as withdrawal or detoxification risks relapse and treatment dropout. Medication increases may be needed with advancing pregnancy, and are not associated with more severe neonatal abstinence syndrome (NAS). Switching medication prenatally is usually not recommended as it can destabilize opioid abstinence. Postnatally, breastfeeding is seen as beneficial for the infant for women who are maintained on a stable dose of opioid agonist medication. Less is known about ideal pain management and postpartum dosing regimens. NAS appears generally less severe following prenatal exposure to buprenorphine versus methadone. Frontline NAS medication treatments include protocol-driven methadone and morphine dosing in the context of nonpharmacological supports.

CONCLUSIONS

Women with OUD can be treated with methadone or buprenorphine during pregnancy. NAS is an expected and manageable condition. Although research has substantially advanced, opportunities to guide future research to improve maternal and infant outcomes are provided.

Moms Supporting Moms: Digital Storytelling With Peer Mentors in Recovery From Substance Use

Substance use disorder (SUD) is a growing issue nationally, and SUD in pregnancy has significant consequences for mothers and their children. This article describes findings from a pilot project that used digital storytelling as a mechanism for understanding substance use and recovery from the perspective of women in recovery from SUD in pregnancy who worked as peer mentors with pregnant women currently experiencing SUD. Research on peer mentorship has primarily focused on outcomes for mentees but not the experience of the peer mentors themselves. In this qualitative study, a 3-day digital storytelling workshop was conducted with five women in recovery serving as peer mentors in their community. Each mentor also participated in an individual, in-depth interview. The digital storytelling workshop process helped peer mentors make linkages between their past substance use experiences to their present work of recovery, and fostered deep social connections between mentors through the shared experience. The workshop process also elicited a sense of hope among participants, which served as groundwork for developing advocacy-based efforts. Digital storytelling may be therapeutic for women in recovery and has the potential to be integrated into recovery programs to bolster hope and social support among participants.

Pharmacologic Treatment of Opioid Addiction During Pregnancy

Opioid addiction during pregnancy presents a treatment challenge to clinicians and women alike. Untreated addiction can lead to poor maternal and fetal health outcomes. Medication-assisted treatment is the standard of care, and methadone is the current drug of choice for treatment. Emerging evidence also supports the use of buprenorphine during pregnancy. Both methadone and buprenorphine have risks and benefits that should be explored before initiating treatment. Clinicians who work in obstetrics and in addiction treatment can collaborate and coordinate treatment to ensure optimal maternal and fetal outcomes. Women undergoing treatment will require frequent monitoring, particularly in the third trimester. Neonates born to women receiving treatment may have withdrawal symptoms and require additional treatment.

Breastfeeding support and opiate dependence: A think aloud study

OBJECTIVE

international guidelines recommend the promotion and protection of breastfeeding for the substance exposed mother and baby. Yet few studies have explored the facilitators, moderators and barriers to successful breastfeeding for women enrolled on opiate maintenance treatment, or suggested targeted support strategies. The aim of this study was to explore the views of women with opiate dependence on proposed elements for inclusion in a breastfeeding support intervention.

DESIGN

a qualitative study using think aloud technique.

SETTING

tertiary maternity hospital in the North-East of Scotland. Interviews conducted between November 2013 and March 2014.

PARTICIPANTS

6 opiate dependent women within 6 months of giving birth. Participants were enrolled on opiate medication treatment during their pregnancy, had initiated breastfeeding and accessed in-hospital breastfeeding support.

FINDINGS

an intervention founded on practical, informational and environmental elements was endorsed as supportive of continued breastfeeding of an infant at risk of Neonatal Abstinence Syndrome. Opiate dependent women were more receptive to strategies promoting a person-centered approach that were specific to their individualized infant feeding needs and delivered within an emotionally supportive environment. Barriers to the acceptability of breastfeeding advice included discouraging, prescriptive and judgemental healthcare actions and attitudes.

KEY CONCLUSIONS

there are distinct facilitators, modifiers and barriers to breastfeeding within the context of opiate exposure. Using this awareness to underpin the key features of the design should enhance maternal receptiveness, acceptability and usability of the support intervention.

IMPLICATIONS FOR PRACTICE

additional and tailored support interventions are required to meet the specific needs of breastfeeding an infant experiencing opiate withdrawal. The elimination of disempowering institutional actions and attitudes is imperative if a conducive environment in which opiate dependent women feel supported is to be achieved.

Decreasing Total Medication Exposure and Length of Stay While Completing Withdrawal for Neonatal Abstinence Syndrome during the Neonatal Hospital Stay

INTRODUCTION

Neonatal abstinence syndrome (NAS) is a rapidly growing public health concern that has considerably increased health-care utilization and health-care costs. In an effort to curtail costs, attempts have been made to complete withdrawal as an outpatient. Outpatient therapy has been shown to prolong exposure to medications, which may negatively impact neurodevelopmental and behavioral outcomes. We hypothesized that the implementation of a modified NAS protocol would decrease total drug exposure and length of stay while allowing for complete acute drug withdrawal during the neonatal hospital stay.

METHODS

Data were derived retrospectively from medical records of term (≥37 0/7) infants with NAS who were treated with pharmacologic therapy in the University of Louisville Hospital Neonatal Intensive Care Unit from 2005 to 2015. The pharmacologic protocol (SP1) for infants treated between 2005 and March 2014 (n = 146) dosed oral morphine every 4 h and utilized phenobarbital as adjuvant therapy. Protocol 2 (SP2) initiated after March 2014 (n = 44) dosed morphine every 3 h and used clonidine as adjuvant therapy. Charts were reviewed for demographic information and maternal drug history. Maternal and infant toxicology screens were recorded. The length of morphine therapy and need for adjuvant drug therapy were noted. Length of stay was derived from admission and discharge dates.

RESULTS

The length of morphine therapy was decreased by 8.5 days from 35 to 26.5 days (95% CI 4.5-12 days) for infants treated with SP2 vs. SP1 (p < 0.001). The need for adjuvant pharmacologic therapy was decreased by 24% in patients treated with SP2 vs. SP1 (p = 0.004). The length of stay was decreased by 9 days from 42 to 33 days (95% CI 5.1-13 days) for infants treated with SP2 vs. SP1 (p < 0.001). The decreased length of stay resulted in an average reduction of hospital charges by $27,090 per patient in adjusted 2015 US Dollars.

CONCLUSION

This study demonstrates that total drug exposure and length of stay can be reduced while successfully completing acute withdrawal during the neonatal hospital stay.

Changes in breastfeeding initiation at hospital discharge between first and second births in Nova Scotia: a population-based cohort study

BACKGROUND

Breastfeeding has well-recognized health benefits for infants and mothers. However, little research has been conducted to investigate changes in breastfeeding from one pregnancy to another. This study was conducted to describe rates of breastfeeding initiation at hospital discharge for women's first and second births and to identify factors associated with changes in initiation at the second birth.

METHODS

We conducted a longitudinal, population-based cohort study involving women residing in Nova Scotia who delivered a first and second live-born singleton between 2007 and 2013. Separate analyses were conducted among women who breastfed their first infant and among women who did not breastfeed their first infant.

RESULTS

Of the 9643 (82.6%) mothers who initiated breastfeeding in the first birth, 973 (10.3%) did not initiate breastfeeding in the second birth. Of first-birth noninitiators, 526 (26.3%) initiated breastfeeding in the second birth. With the exception of smoking and cesarean births, factors that were associated with breastfeeding initiation in the second birth depended on breastfeeding initiation status in the first birth. These factors were associated with increased odds of not breastfeeding in the second birth among the subset of mothers who breastfed in the first birth, and decreased odds of breastfeeding in the second birth among the subset of mothers who did not breastfeed in the first birth.

INTERPRETATION

Most women continue the same method of infant feeding after their first and second births. Identifying factors associated with change in breastfeeding status between the first and second births may help to inform interventions for optimal breastfeeding initiation in the second birth.