Neonatal Opioid Withdrawal Syndrome: A Comparison of As-Needed Pharmacotherapy

Neonatal Opioid Withdrawal Syndrome Treatment Guidelines and Birth Hospital Utilization

BACKGROUND AND OBJECTIVES

In November 2020, the American Academy of Pediatrics published guidelines for management of neonatal opioid withdrawal syndrome (NOWS), recommending nonpharmacologic treatment as the first-line approach, unless pharmacologic treatment is needed for severe NOWS. Using data from tertiary care pediatric hospitals, we examined the impact of the guidelines on use of pharmacotherapy, length of stay, and NICU admission for infants with NOWS.

METHODS

We extracted birth hospitalization data for newborns diagnosed with NOWS discharged from 2019 to 2022 from the Pediatric Health Information System. We compared hospital utilization and pharmacologic treatment pre- and postguidelines and used interrupted time series regression to examine trends over time.

RESULTS

We included N = 824 newborns (n = 434 pre, n = 390 post) with NOWS from 11 hospitals. The use of pharmacologic treatment was significantly lower in the postguidelines period (59.0% pre versus 50.3% post; P = .01). Median length of stay was similar pre and post (P = .55). NICU admission was significantly lower in the postguidelines period (78.6% pre versus 46.7% post; P < .001), with an immediate decrease (β = -23.0%; P < .001) and a decrease over time in the postguidelines period (β = -0.7% per month; P = .03). Most hospitals reduced pharmacologic treatment (8 of 11; 73%) and NICU use (10 of 11; 91%) postguidelines.

CONCLUSIONS

There was a reduction in the use of pharmacologic treatment and NICU utilization for infants with NOWS after the release of American Academy of Pediatrics guidelines for NOWS management.

Short term outcomes of neonatal opioid withdrawal syndrome: a comparison of two approaches

OBJECTIVE

To evaluate outcomes in opioid exposed neonates (OENs) assessed by the Eat, Sleep, Console (ESC) tool compared to the Finnegan Neonatal Abstinence Scoring System (FNASS).

METHODS

Retrospective analysis of a statewide database of OENs from 2017 to 2020 with birthing hospitals classified based on the assessment tool used. Four main outcomes were examined using multivariable and Poisson logistic regression models.

RESULTS

Of 2375 OENs, 42.1% received pharmacotherapy (PT) with a consistent decrease in PT, length of treatment (LOT), and length of stay (LOS) over the study period. There was no change in use of mother's own milk (MoM). While outcomes were significantly associated with several specific variables, there were no differences in outcomes between assessment methods.

CONCLUSION

While there was a significant decrease over time in PT, LOT, and LOS, improvements were independent of the assessment tool used and likely related to the increased use of non-pharmacologic care.

Advances in the Care of Infants With Prenatal Opioid Exposure and Neonatal Opioid Withdrawal Syndrome

A significant number of advances have been made in the last 5 years with respect to the identification, diagnosis, assessment, and management of infants with prenatal opioid exposure and neonatal opioid withdrawal syndrome (NOWS) from birth to early childhood. The primary objective of this review is to summarize major advances that will inform the clinical management of opioid-exposed newborns and provide an overview of NOWS care to promote the implementation of best practices. First, advances with respect to standardizing the clinical diagnosis of NOWS will be reviewed. Second, the most commonly used assessment strategies are discussed, with a focus on presenting new quality improvement and clinical trial data surrounding the use of the new function-based assessment Eat, Sleep, and Console approach. Third, both nonpharmacologic and pharmacologic treatment modalities are reviewed, highlighting clinical trials that have compared the use of higher calorie and low lactose formula, vibrating crib mattresses, morphine compared with methadone, buprenorphine compared with morphine or methadone, the use of ondansetron as a medication to prevent the need for NOWS opioid pharmacologic treatment, and the introduction of symptom-triggered dosing compared with scheduled dosing. Fourth, maternal, infant, environmental, and genetic factors that have been found to be associated with NOWS severity are highlighted. Finally, emerging recommendations on postdelivery hospitalization follow-up and developmental surveillance are presented, along with highlighting ongoing and needed areas of research to promote infant and family well-being for families impacted by opioid use.

Effects of prenatal opioid exposure on synaptic adaptations and behaviors across development

In this review, we focus on prenatal opioid exposure (POE) given the significant concern for the mental health outcomes of children with parents affected by opioid use disorder (OUD) in the view of the current opioid crisis. We highlight some of the less explored interactions between developmental age and sex on synaptic plasticity and associated behavioral outcomes in preclinical POE research. We begin with an overview of the rich literature on hippocampal related behaviors and plasticity across POE exposure paradigms. We then discuss recent work on reward circuit dysregulation following POE. Additional risk factors such as early life stress (ELS) could further influence synaptic and behavioral outcomes of POE. Therefore, we include an overview on the use of preclinical ELS models where ELS exposure during key critical developmental periods confers considerable vulnerability to addiction and stress psychopathology. Here, we hope to highlight the similarity between POE and ELS on development and maintenance of opioid-induced plasticity and altered opioid-related behaviors where similar enduring plasticity in reward circuits may occur. We conclude the review with some of the limitations that should be considered in future investigations. This article is part of the Special Issue on 'Opioid-induced addiction'.