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Dempsey S, O' Grady MJ. Current management of neonatal abstinence syndrome: a survey of practice in the UK and Ireland. Arch Dis Child Fetal Neonatal Ed 2024; 109:261-264. [PMID: 37879885 DOI: 10.1136/archdischild-2023-326204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 10/11/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVE To study the current management practices of neonatal abstinence syndrome (NAS) throughout the UK and Ireland and identify changes in practice from the most recent survey in 2008. DESIGN Postal questionnaire to a consultant paediatrician or neonatologist in all 215 neonatal units in the UK and Ireland in January 2020. RESULTS Response rate was 62%. An objective scoring tool was used in 97% of units and the Finnegan score was favoured by 70%. Morphine sulfate use as first line for the treatment of opiate withdrawal was almost universal and 70% used a dose of 40 µg/kg every 4 hours (240 µg/kg/day). Phenobarbitone administration as a second-line agent for opiate withdrawal increased to 61% of units with significant reductions in chloral hydrate and chlorpromazine use compared with the previous survey. Morphine sulfate and phenobarbitone remain the preferred first-line and second-line agents, respectively, for polysubstance withdrawal. There was a significant increase in chlorpromazine use as first line for polydrug withdrawal (1.5-14.2%). The practice of units discharging infants' home on medication increased to 46% from 29%. All units now permit breastfeeding in mothers taking methadone, compared with 81% previously. CONCLUSION AND RELEVANCE Compared with the previous survey, improvements in evidence-based practices were noted, highlighting the benefits of this type of research. Nonetheless, significant variation still exists in some aspects of the management of NAS. Post-discharge follow-up varies widely, with particular deficits in ophthalmology follow-up.
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Affiliation(s)
- Sharon Dempsey
- Department of Paediatrics, Regional Hospital Mullingar, Mullingar, Westmeath, Ireland
| | - Michael J O' Grady
- Department of Paediatrics, Regional Hospital Mullingar, Mullingar, Westmeath, Ireland
- Women's and Children's Health, University College Dublin, Dublin, Ireland
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2
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Miller MR, MacMillan KDL. Growing together: Optimization of care through quality improvement for the mother/infant dyad affected by perinatal opioid use. Semin Perinatol 2024; 48:151907. [PMID: 38702266 DOI: 10.1016/j.semperi.2024.151907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/06/2024]
Abstract
The care of the dyad affected by opioid use disorder (OUD) requires a multi-disciplinary approach that can be challenging for institutions to develop and maintain. However, over the years, many institutions have developed quality improvement (QI) initiatives aimed at improving outcomes for the mother, baby, and family. Over time, QI efforts targeting OUD in the perinatal period have evolved from focusing separately on the mother and baby to efforts addressing care of the dyad and family during pregnancy, delivery, and postpartum. Here, we review recent and impactful QI initiatives that serve as examples of work improving outcomes for this population. Further, we advocate that this work be done through a racial equity lens, given ongoing inequities in the care of particularly non-white populations with substance use disorders. Through QI frameworks, even small interventions can result in meaningful changes to the care of babies and families and improved outcomes.
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Affiliation(s)
- Megan R Miller
- Obstetrics & Gynecology, UMMS-Baystate Medical Center, United States.
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Gersch H, Shah D, Chroust A, Bailey B. Can umbilical cord testing add to maternal urine drug screen for evaluation of infants at risk of neonatal opioid withdrawal syndrome? J Matern Fetal Neonatal Med 2023; 36:2211706. [PMID: 37183045 DOI: 10.1080/14767058.2023.2211706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
OBJECTIVE This study evaluated maternal urine drug screen (UDS) at delivery and umbilical cord drug testing and its association with neonatal opioid withdrawal syndrome (NOWS) diagnosis and severity following opioid exposed pregnancy. METHODS A retrospective chart review of 770 mother-infant dyads at five birthing hospitals in the United States Appalachian region for a five-year period was performed. Variables of interest included dyad demographics, results of maternal UDS at delivery and umbilical cord drug testing, and three neonatal outcomes: NOWS diagnosis, pharmacologic treatment administered for NOWS, and length of hospital stay (LOS) of the newborn. RESULTS Opioid-positivity was between 8.5% and 66.3% based on maternal UDS at delivery or umbilical cord testing. Odds of NOWS diagnosis and increased infant LOS was best associated with opioid detection in maternal UDS alone (OR = 5.62, 95% CI [3.06, 10.33] and OR = 8.33, 95% CI [3.67, 18.89], respectively). However, odds of pharmacologic treatment for NOWS was best associated with opioid detection in both maternal UDS and umbilical cord testing on the same dyad (OR = 3.22, 95% CI [1.14, 9.09]). CONCLUSION Maternal UDS is a better option compared to umbilical cord testing for evaluation of opioid-exposed infants and risk of NOWS diagnosis and increased infant LOS.
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Affiliation(s)
- Hannah Gersch
- Department of Pediatrics, Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Darshan Shah
- Department of Pediatrics, Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Alyson Chroust
- Department of Psychology, College of Arts and Sciences, East Tennessee State University, Johnson City, TN, USA
| | - Beth Bailey
- Department of Pediatrics, Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
- College of Medicine, Central Michigan University, Mt. Pleasant, MI, USA
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4
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Baldo BA. Neonatal opioid toxicity: opioid withdrawal (abstinence) syndrome with emphasis on pharmacogenomics and respiratory depression. Arch Toxicol 2023; 97:2575-2585. [PMID: 37537419 DOI: 10.1007/s00204-023-03563-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 07/24/2023] [Indexed: 08/05/2023]
Abstract
The increasing use of opioids in pregnant women has led to an alarming rise in the number of cases of neonates with drug-induced withdrawal symptoms known as neonatal opioid withdrawal syndrome (NOWS). NOWS is a toxic heterogeneous condition with many neurologic, autonomic, and gastrointestinal symptoms including poor feeding, irritability, tachycardia, hypertension, respiratory defects, tremors, hyperthermia, and weight loss. Paradoxically, for the management of NOWS, low doses of morphine, methadone, or buprenorphine are administered. NOWS is a polygenic disorder supported by studies of genomic variation in opioid-related genes. Single-nucleotide polymorphisms (SNPs) in CYP2B6 are associated with variations in NOWS infant responses to methadone and SNPs in the OPRM1, ABCB1, and COMT genes are associated with need for treatment and length of hospital stay. Epigenetic gene changes showing higher methylation levels in infants and mothers have been associated with more pharmacologic treatment in the case of newborns, and for mothers, longer infant hospital stays. Respiratory disturbances associated with NOWS are not well characterized. Little is known about the effects of opioids on developing neonatal respiratory control and respiratory distress (RD), a potential problem for survival of the neonate. In a rat model to test the effect of maternal opioids on the developing respiratory network and neonatal breathing, maternal-derived methadone increased apneas and lessened RD in neonates at postnatal (P) days P0 and P1. From P3, breathing normalized with age suggesting reorganization of respiratory rhythm-generating circuits at a time when the preBötC becomes the dominant inspiratory rhythm generator. In medullary slices containing the preBötC, maternal opioid treatment plus exposure to exogenous opioids showed respiratory activity was maintained in younger but not older neonates. Thus, maternal opioids blunt centrally controlled respiratory frequency responses to exogenous opioids in an age-dependent manner. In the absence of maternal opioid treatment, exogenous opioids abolished burst frequencies at all ages. Prenatal opioid exposure in children stunts growth rate and development while studies of behavior and cognitive ability reveal poor performances. In adults, high rates of attention deficit disorder, hyperactivity, substance abuse, and poor performances in intelligence and memory tests have been reported.
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Affiliation(s)
- Brian A Baldo
- Kolling Institute of Medical Research, Royal North Shore Hospital of Sydney, Sydney, NSW, 2065, Australia.
- Department of Medicine, University of Sydney, Sydney, NSW, 2000, Australia.
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Gomez Pomar E. A mini review of what matters in the management of NAS, is ESC the best care? Front Pediatr 2023; 11:1239107. [PMID: 37520058 PMCID: PMC10376704 DOI: 10.3389/fped.2023.1239107] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 06/28/2023] [Indexed: 08/01/2023] Open
Abstract
As the use of opioids and polysubstance by pregnant women has increased over the years, there has also been a sharp increase in cases of neonatal abstinence syndrome (NAS). Classically, infants affected by NAS have been cared for in neonatal intensive care units resulting in an increase of healthcare expenditure and resource utilization as well as separation from the families. Consequently, the Eat, Sleep, and Console (ESC) tool was developed and promoted as a novel method that focuses on maternal/infant dyad during hospital stay while decreasing the use of pharmacological interventions and therefore decreasing the length of stay and healthcare expenditure. Thus, it has been implemented in several hospitals in the United States. Although the training of staff has been proposed and the interventions of sleep, eat, and console are defined, there still exists a lack of standardization of this practice specifically in regard to the type of associated non-pharmacological practices as well as the reports of its short- and long-term outcomes.
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Affiliation(s)
- Enrique Gomez Pomar
- Division of Neonatology, Department of Pediatrics, University of Kentucky, Lexington, KY, United States
- Department of Pediatrics, St. Bernards Regional Medical Center, Jonesboro, AR, United States
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Ceccanti M, Blum K, Bowirrat A, Dennen CA, Braverman ER, Baron D, Mclaughlin T, Giordano J, Gupta A, Downs BW, Bagchi D, Barh D, Elman I, Thanos PK, Badgaiyan RD, Edwards D, Gold MS. Future Newborns with Opioid-Induced Neonatal Abstinence Syndrome (NAS) Could Be Assessed with the Genetic Addiction Risk Severity (GARS) Test and Potentially Treated Using Precision Amino-Acid Enkephalinase Inhibition Therapy (KB220) as a Frontline Modality Instead of Potent Opioids. J Pers Med 2022; 12:2015. [PMID: 36556236 PMCID: PMC9782293 DOI: 10.3390/jpm12122015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/14/2022] [Accepted: 11/25/2022] [Indexed: 12/12/2022] Open
Abstract
In this nonsystematic review and opinion, including articles primarily selected from PubMed, we examine the pharmacological and nonpharmacological treatments of neonatal abstinence syndrome (NAS) in order to craft a reasonable opinion to help forge a paradigm shift in the treatment and prevention of primarily opioid-induced NAS. Newborns of individuals who use illicit and licit substances during pregnancy are at risk for withdrawal, also known as NAS. In the US, the reported prevalence of NAS has increased from 4.0 per 1000 hospital births in 2010 to 7.3 per 1000 hospital births in 2017, which is an 82% increase. The management of NAS is varied and involves a combination of nonpharmacologic and pharmacologic therapy. The preferred first-line pharmacological treatment for NAS is opioid therapy, specifically morphine, and the goal is the short-term improvement in NAS symptomatology. Nonpharmacological therapies are individualized and typically focus on general care measures, the newborn-parent/caregiver relationship, the environment, and feeding. When used appropriately, nonpharmacologic therapies can help newborns with NAS avoid or reduce the amount of pharmacologic therapy required and the length of hospitalization. In addition, genetic polymorphisms of the catechol-o-methyltransferase (COMT) and mu-opioid receptor (OPRM1) genes appear to affect the length of stay and the need for pharmacotherapy in newborns with prenatal opioid exposure. Therefore, based on this extensive literature and additional research, this team of coauthors suggests that, in the future, in addition to the current nonpharmacological therapies, patients with opioid-induced NAS should undergo genetic assessment (i.e., the genetic addiction risk severity (GARS) test), which can subsequently be used to guide DNA-directed precision amino-acid enkephalinase inhibition (KB220) therapy as a frontline modality instead of potent opioids.
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Affiliation(s)
- Mauro Ceccanti
- Società Italiana per il Trattamento dell’Alcolismo e le sue Complicanze (SITAC), ASL Roma1, Sapienza University of Rome, 00185 Rome, Italy
| | - Kenneth Blum
- The Kenneth Blum Behavioral & Neurogenetic Institute, Austin, TX 78701, USA
- Division of Addiction Research & Education, Center for Mental Health & Sports, Exercise and Global Mental Health, Western University Health Sciences, Pomona, CA 91766, USA
- Institute of Psychology, ELTE Eötvös Loránd University, Egyetem tér 1-3, H-1053 Budapest, Hungary
- Department of Psychiatry, School of Medicine, University of Vermont, Burlington, VT 05405, USA
- Department of Psychiatry, Wright State University Boonshoft School of Medicine and Dayton VA Medical Centre, Dayton, OH 45324, USA
- Reward Deficiency Clinics of America, Austin, TX 78701, USA
- Center for Genomics and Applied Gene Technology, Institute of Integrative Omics and applied Biotechnology (IIOAB), Nonakuri, Purba Medinipur, West Bengal 721172, India
- Department of Precision Behavioral Management, Transplicegen Therapeutics, Inc., LLC., Austin, TX 78701, USA
- Department of Molecular Biology and Adelson School of Medicine, Ariel University, Ariel 40700, Israel
| | - Abdalla Bowirrat
- Department of Molecular Biology and Adelson School of Medicine, Ariel University, Ariel 40700, Israel
| | - Catherine A. Dennen
- Department of Family Medicine, Jefferson Health Northeast, Philadelphia, PA 19107, USA
| | - Eric R. Braverman
- The Kenneth Blum Behavioral & Neurogenetic Institute, Austin, TX 78701, USA
| | - David Baron
- Division of Addiction Research & Education, Center for Mental Health & Sports, Exercise and Global Mental Health, Western University Health Sciences, Pomona, CA 91766, USA
| | | | - John Giordano
- The Kenneth Blum Behavioral & Neurogenetic Institute, Austin, TX 78701, USA
- Ketamine Infusion Clinic of South Florida, Pompano Beach, FL 33062, USA
| | - Ashim Gupta
- Future Biologics, Lawrenceville, GA 30043, USA
| | - Bernard W. Downs
- The Kenneth Blum Behavioral & Neurogenetic Institute, Austin, TX 78701, USA
| | - Debasis Bagchi
- The Kenneth Blum Behavioral & Neurogenetic Institute, Austin, TX 78701, USA
- Department of Pharmaceutical Sciences, Southern University College of Pharmacy, Houston, TX 77004, USA
| | - Debmalya Barh
- Center for Genomics and Applied Gene Technology, Institute of Integrative Omics and applied Biotechnology (IIOAB), Nonakuri, Purba Medinipur, West Bengal 721172, India
- Department of Genetics, Ecology and Evolution, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil
| | - Igor Elman
- Center for Pain and the Brain (PAIN Group), Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children’s Hospital, Harvard School of Medicine, Boston, MA 02115, USA
| | - Panayotis K. Thanos
- Behavioral Neuropharmacology and Neuroimaging Laboratory, Clinical Research Institute on Addictions, Department of Pharmacology and Toxicology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY 14203, USA
| | - Rajendra D. Badgaiyan
- Department of Psychiatry, South Texas Veteran Health Care System, Audie L. Murphy Memorial VA Hospital, Long School of Medicine, University of Texas Medical Center, San Antonio, TX 78229, USA
| | - Drew Edwards
- Neurogenesis Project, Jacksonville, FL 32223, USA
| | - Mark S. Gold
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, USA
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Sutter MB, Watson H, Yonke N, Weitzen S, Leeman L. Morphine versus methadone for neonatal opioid withdrawal syndrome: a randomized controlled pilot study. BMC Pediatr 2022; 22:345. [PMID: 35705944 PMCID: PMC9202148 DOI: 10.1186/s12887-022-03401-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 05/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Neonatal Opioid Withdrawal Syndrome (NOWS) is a significant public health issue and while millions of neonates are affected each year, an optimal pharmacologic weaning protocol has yet to be demonstrated. In this study, we compare hospital length of stay (LOS) and length of treatment (LOT) for treatment of neonatal opioid withdrawal (NOWS) with morphine versus methadone. METHODS This was a single-site, open-label, randomized controlled pilot study conducted from October 2016-September 2018. Infants were eligible if their primary in-utero drug exposure was heroin, oral opioids, or methadone and they were born at greater than or equal to 34 weeks gestation. Infants were excluded for serious medical comorbidities and primary in-utero exposure to buprenorphine. RESULTS Sixty-one infants were enrolled; 30 were randomized to methadone treatment, and 31 to morphine treatment. Overall 46% of infants required treatment for NOWS. LOS and LOT for infants treated with morphine was 17.9 days and 14.7 days respectively, compared to 16.1 days and 12.8 days for babies treated with methadone (p = 0.5, p = 0.54). Infants treated with morphine received lower total morphine equivalents than those treated with methadone (9.7 vs. 33, p < 0.01). Three treated infants in the methadone group required transfer to the Neonatal Intensive Care Unit, versus no infants in the morphine group. CONCLUSIONS Infants treated with morphine versus methadone had no significant differences in LOS or LOT in this pilot study. Infants treated with methadone received up to 3 times the opioid based on morphine equivalents as infants treated with morphine and had more transfers to the NICU for over sedation. CLINICAL TRIAL REGISTRATION Morphine Versus Methadone for Opiate Exposed Infants With Neonatal Abstinence Syndrome NCT02851303 , initiated 01/08/2016.
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Affiliation(s)
- Mary Beth Sutter
- Department of Family Medicine, Alpert Medical School of Brown University, Providence, RI, USA.
| | | | - Nicole Yonke
- Family Medicine of Southwest Washington, Vancouver, WA, USA
| | | | - Lawrence Leeman
- Department of Family and Community Medicine, Department of Obstetrics, University of New Mexico, Albuquerque, NM, USA
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Kainth D, Kathiresan P, Bhad R, Rao R, Verma A. A Hyperalert Newborn. Neoreviews 2022; 23:e413-e415. [PMID: 35641455 DOI: 10.1542/neo.23-6-e413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | | | - Roshan Bhad
- Psychiatry, All India Institute of Medical Sciences, New Delhi
| | - Ravindra Rao
- Psychiatry, All India Institute of Medical Sciences, New Delhi
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Umer A, Lilly C, Curry H, Kumar A, Maxwell S, Govindaswami B, Plumley J, John C, Smith MC. Variations and similarities in neonatal abstinence syndrome care and management across tertiary care hospitals in West Virginia. J Perinatol 2022; 42:397-398. [PMID: 34667250 DOI: 10.1038/s41372-021-01248-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/23/2021] [Accepted: 10/08/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Amna Umer
- Department of Pediatrics, School of Medicine, West Virginia University, Morgantown, WV, 26506, USA.
| | - Christa Lilly
- Department of Epidemiology and Biostatistics, School of Public Health, West Virginia University, Morgantown, WV, 26506, USA
| | - Hunter Curry
- School of Pharmacy, West Virginia University, Morgantown, WV, 26506, USA
| | - Aishwarya Kumar
- School of Medicine, West Virginia School of Osteopathic Medicine, Lewisburg, WV, 24901, USA
| | - Stefan Maxwell
- Department of Pediatrics, WV School of Medicine (Charleston division) PEDIATRIX Medical Group, Women & Children's Hospital, Charleston, WV, 25304, USA
| | - Balaji Govindaswami
- Department of Pediatrics, Marshall University Joan C Edwards School of Medicine, Huntington, WV, 25701, USA
| | - Jodi Plumley
- Department of Pediatrics, Marshall University Joan C Edwards School of Medicine, Huntington, WV, 25701, USA
| | - Collin John
- Department of Pediatrics, School of Medicine, West Virginia University, Morgantown, WV, 26506, USA
| | - M Cody Smith
- Department of Pediatrics, School of Medicine, West Virginia University, Morgantown, WV, 26506, USA
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Morris E, Bardsley T, Schulte K, Seidel J, Shakib JH, Buchi KF, Fung CM. Hospital Outcomes of Infants with Neonatal Opioid Withdrawal Syndrome at a Tertiary Care Hospital with High Rates of Concurrent Nonopioid (Polysubstance) Exposure. Am J Perinatol 2022; 39:387-393. [PMID: 32892326 PMCID: PMC8632549 DOI: 10.1055/s-0040-1716490] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Neonatal opioid withdrawal syndrome (NOWS) describes infants' withdrawal signs and symptoms after birth due to an interruption of prenatal opioid exposure. Many infants with NOWS are also exposed to nonopioids, however. This study was to determine hospital outcomes of infants exposed to opioids alone or coexposed with nonopioid substances (polysubstance). STUDY DESIGN We reviewed infants of ≥34 weeks of gestation with prenatal opioid exposure from April 2015 to May 2018. We compared the median lengths of stay (LOS) and treatment (LOT) and the percentages of infants requiring pharmacologic and adjunctive treatment in infants exposed to opioids alone or polysubstance. We used Wilcoxon's test for continuous outcomes or Chi-squared test for categorical outcomes to determine statistical significance. We used multivariable regression model to calculate each drug category's estimates of adjusted mean ratios for LOS and LOT plus estimates of adjusted odds ratios for pharmacologic/adjunctive treatments. RESULTS Of the 175 infants, 33 (19%) infants had opioid exposure alone. Opioid exposure included short- and/or long-acting opioids. A total of 142 (81%) had polysubstance exposure with 47% of mothers using nicotine products. We saw similar hospital outcomes between infants exposed to opioids alone or polysubstance; however, a higher percentage of infants with both short- and long-acting opioid exposure required pharmacologic treatment compared with either opioid alone. Focusing on individual drug categories, we detected differential hospital outcomes in which short-acting opioids decreased LOT, whereas long-acting opioids increased LOS, LOT, and need for pharmacologic and adjunctive treatment. Coexposure of opioids with stimulants decreased LOT and reduced need for adjunctive treatment. Coexposures with antidepressants increased LOT, while with antiepilepetics increased LOS. CONCLUSION Because infants with NOWS often have coexposures to other nonopioid substances, appreciating the associated risks of individual or combination of drugs in modulating hospital outcomes may help counsel families on their infants' expected hospital course. KEY POINTS · Hospital outcomes were similar between infants exposed to opioids alone or polysubstance including opioids.. · Infants with short- and long-acting opioids required pharmacologic treatment more often than either opioid alone.. · Differential hospital outcomes exist for various co-exposures of opioids with nonopioids..
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Affiliation(s)
- Erin Morris
- Department of Pediatrics, Residency & Fellowship Program, Salt Lake City, Utah
| | - Tyler Bardsley
- Division of Epidemiology, University of Utah Study Design and Biostatistics Center, University of Utah School of Medicine, Salt Lake City, Utah
| | - Krista Schulte
- College of Nursing, University of Utah, Salt Lake City, Utah
| | - Jeanette Seidel
- College of Nursing, University of Utah, Salt Lake City, Utah
| | - Julie H. Shakib
- Division of General Pediatrics, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Karen F. Buchi
- Division of General Pediatrics, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Camille M. Fung
- Division of Pediatric Neonatology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
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11
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Harris JB, Holmes AP. Comparison of Two Morphine Dosing Strategies in the Management of Neonatal Abstinence Syndrome. J Pediatr Pharmacol Ther 2022; 27:151-156. [DOI: 10.5863/1551-6776-27.2.151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 06/09/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE
The incidence of neonatal abstinence syndrome (NAS) has increased in recent years. Treatment approaches usually involve opioid replacement; however, the optimal treatment strategy is unknown. This study sought to determine the impact of weight- and symptom-based morphine dosing strategies on LOS and medication exposure in patients with NAS.
METHODS
A retrospective review was conducted from May 2015 to June 2017 at 2 NICUs within a health-system using different dosing approaches for NAS. Data were compared using Fisher exact tests for categorical data and t tests and Wilcoxon ranked sums for continuous data.
RESULTS
Baseline demographics were well-matched except for postmenstrual age at morphine initiation (p = 0.04). The weight-based group had a larger initial morphine dose (p < 0.001) and fewer number of steps to maximum morphine dose (p = 0.009). There were no differences between groups in LOS, number of dose adjustments, doses administered, weaning steps, maximum dose, or need to re-escalate dosing. There was also no difference between the first 3 modified Finnegan scores (MFS) after transferring patients to a neonatology service. Neonates with symptom-based dosing had a higher maximum MFS (p = 0.024). Neonates in the symptom-based group required adjunct therapy more often (p < 0.0001).
CONCLUSIONS
Data indicate the dosing strategy impacts number of steps to reach maximum dose and need for adjunctive therapy. Weight-based dosing may decrease the number of steps required to reach the morphine maximum dose and the need for adjunctive therapy by controlling NAS symptoms earlier.
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Affiliation(s)
- John Brock Harris
- Wingate University School of Pharmacy (JBH), Wingate University, Wingate, NC
- Novant Health Hemby Children's Hospital (JBH), Charlotte, NC
| | - Amy P. Holmes
- Brenner Children's Hospital (APH), Wake Forest Baptist Medical Center, Winston-Salem, NC
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12
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Miller JS, Anderson JG. Factors in children with a history of neonatal abstinence syndrome at 10 years of age: Evidence from the maternal lifestyle study. J SPEC PEDIATR NURS 2022; 27:e12358. [PMID: 34472206 DOI: 10.1111/jspn.12358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 07/26/2021] [Accepted: 08/23/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE Few studies have addressed the impact of prior prenatal substance exposure and current household environment on neurodevelopmental health in children with a history of neonatal abstinence syndrome (NAS). This study aimed to describe the prenatal exposures, household environment, and neurodevelopmental health at 10 years of age among children with a history of NAS. DESIGN AND METHODS This study was a retrospective, descriptive design using data from the Maternal Lifestyle Study. Descriptive analyses were conducted. A total of 234 children with a history of NAS were included in this study. Variables selected based on the socio-ecological model included prenatal exposures, household environment, and neurodevelopmental health outcomes. RESULTS In this sample, most children were male (63%) with prenatal polysubstance exposure (80%). The majority lived in a home where substance use occurred (68%). Children experienced abnormal cognitive development (26%), language disorders (24%), learning disorders (23%), and abnormal behavioral development (16%). IMPLICATIONS This study extends the description of children with a history of NAS beyond 5 years of age. Pediatric nurses can ensure that children with a history of NAS receive neurodevelopmental screening up to and beyond 10 years of age.
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Affiliation(s)
| | - Joel G Anderson
- College of Nursing, University of Tennessee, Knoxville, Tennessee, USA
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13
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Milliren CE, Melvin P, Ozonoff A. Pediatric Hospital Readmissions for Infants With Neonatal Opioid Withdrawal Syndrome, 2016-2019. Hosp Pediatr 2021; 11:979-988. [PMID: 34417200 DOI: 10.1542/hpeds.2021-005904] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND AND OBJECTIVES Neonatal opioid withdrawal syndrome (NOWS) is associated with long and costly birth hospitalization and increased readmission risk. Our objective was to examine readmissions in the first year of life for infants diagnosed with NOWS compared with infants without NOWS, adjusting for sociodemographic and clinical factors, and to describe use during readmissions in this population. METHODS Using data from the Pediatric Health Information System, we identified singleton term infants with NOWS and without NOWS or other major condition (by diagnosis codes and All Patient Refined Diagnosis Related Groups coding, respectively) discharged from 2016 to 2019. We predicted time to first readmission within the first year of life using Cox regression analysis. Predictors included NOWS diagnosis, sociodemographic factors, birth NICU use, and birth weight. RESULTS We included 155 885 birth discharges from 17 hospitals (n = 1467 NOWS) with 10 087 readmissions. Unadjusted 1-year readmission rates were 9.9% among NOWS infants versus 6.2% among those without NOWS. The adjusted hazard ratio for readmission within the first year was 1.76 (95% confidence interval: 1.40-2.22) for infants with NOWS versus those without. Readmissions for infants with NOWS were longer and costlier and more likely to require intensive care and mechanical ventilation. Readmissions among infants without NOWS were most commonly for jaundice and respiratory and other infections, whereas respiratory infections were the leading cause of readmissions among NOWS infants. CONCLUSIONS Infants with a NOWS diagnosis were more likely to be readmitted within the first year of life. In future work, researchers should explore potential interventions to prevent readmissions and provide resources to families affected by opioid dependence.
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Affiliation(s)
| | | | - Al Ozonoff
- Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
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14
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Barry JM, Birnbaum AK, Jasin LR, Sherwin CM. Maternal Exposure and Neonatal Effects of Drugs of Abuse. J Clin Pharmacol 2021; 61 Suppl 2:S142-S155. [PMID: 34396555 DOI: 10.1002/jcph.1928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 06/17/2021] [Indexed: 11/08/2022]
Abstract
The public health crisis of pregnant women being exposed to drugs of abuse and of its impact on their unborn children continues to grow at an alarming rate globally. The state of pregnancy is unique, with physiological changes that can lead to changes in the way drugs are handled by the body in both pharmacokinetics and response. These changes place the pregnant woman, fetus, and newborn infant at risk, as many of these drugs can cross the placenta and into breast milk. The substances most commonly linked to harmful effects include alcohol, tobacco, cannabis, stimulants, and opioids. The pharmacological and toxicological changes caused by in utero exposure or breastfeeding exposure are difficult to study, and the full extent of the mechanisms involved are not fully understood. However, these changes can significantly affect the risks of substance abuse and influence optimal treatment of pregnant women with a substance use disorder. In addition, newborns who were exposed to drugs of abuse in utero can experience withdrawal syndromes. Pharmacological management in infants is used to guide and treat withdrawal symptoms, with the goal being to improve the infant's sleep, eating, and comfort. Several barriers may prevent pregnant women from seeking help for substance use, including stigma and interactions with the legal system. Understanding changes in pharmacology, including pharmacokinetic changes that happen during pregnancy, is essential for anticipating the extent of maternal exposure and neonatal adverse effects.
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Affiliation(s)
- Jessica M Barry
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minnesota, Minneapolis, USA
| | - Angela K Birnbaum
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minnesota, Minneapolis, USA
| | - Lisa R Jasin
- Neonatal Intensive Care Unit, Dayton Children's Hospital, Dayton, Ohio, USA
| | - Catherine M Sherwin
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minnesota, Minneapolis, USA.,Department of Pediatrics, Wright State University, Boonshoft School of Medicine, Dayton Children's Hospital, Dayton, Ohio, USA
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Abstract
BACKGROUND Neonatal abstinence syndrome (NAS) due to opioid withdrawal may result in disruption of the mother-infant relationship, sleep-wake abnormalities, feeding difficulties, weight loss, seizures and neurodevelopmental problems. OBJECTIVES To assess the effectiveness and safety of using an opioid for treatment of NAS due to withdrawal from opioids in newborn infants. SEARCH METHODS We ran an updated search on 17 September 2020 in CENTRAL via Cochrane Register of Studies Web and MEDLINE via Ovid. We also searched clinical trials databases, conference proceedings and the reference lists of retrieved articles for eligible trials. SELECTION CRITERIA We included randomised controlled trials (RCTs), quasi- and cluster-RCTs which enrolled infants born to mothers with opioid dependence and who were experiencing NAS requiring treatment with an opioid. DATA COLLECTION AND ANALYSIS Three review authors independently assessed trial eligibility and risk of bias, and independently extracted data. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS We included 16 trials (1110 infants) with NAS secondary to maternal opioid use in pregnancy. Seven studies at low risk of bias were included in sensitivity analysis. Opioid versus no treatment / usual care: a single trial (80 infants) of morphine and supportive care versus supportive care alone reported no difference in treatment failure (risk ratio (RR) 1.29, 95% confidence interval (CI) 0.41 to 4.07; very low certainty evidence). No infant had a seizure. The trial did not report mortality, neurodevelopmental disability and adverse events. Morphine increased days hospitalisation (mean difference (MD) 15.00, 95% CI 8.86 to 21.14; very low certainty evidence) and treatment (MD 12.50, 95% CI 7.52 to 17.48; very low certainty evidence), but decreased days to regain birthweight (MD -2.80, 95% CI -5.33 to -0.27) and duration (minutes) of supportive care each day (MD -197.20, 95% CI -274.15 to -120.25). Morphine versus methadone: there was no difference in treatment failure (RR 1.59, 95% CI 0.95 to 2.67; 2 studies, 147 infants; low certainty evidence). Seizures, neonatal or infant mortality and neurodevelopmental disability were not reported. A single study reported no difference in days hospitalisation (MD 1.40, 95% CI -3.08 to 5.88; 116 infants; low certainty evidence), whereas data from two studies found an increase in days treatment (MD 2.71, 95% CI 0.22 to 5.21; 147 infants; low certainty) for infants treated with morphine. A single study reported no difference in breastfeeding, adverse events, or out of home placement. Morphine versus sublingual buprenorphine: there was no difference in treatment failure (RR 0.79, 95% CI 0.36 to 1.74; 3 studies, 113 infants; very low certainty evidence). Neonatal or infant mortality and neurodevelopmental disability were not reported. There was moderate certainty evidence of an increase in days hospitalisation (MD 11.45, 95% CI 5.89 to 17.01; 3 studies, 113 infants), and days treatment (MD 12.79, 95% CI 7.57 to 18.00; 3 studies, 112 infants) for infants treated with morphine. A single adverse event (seizure) was reported in infants exposed to buprenorphine. Morphine versus diluted tincture of opium (DTO): a single study (33 infants) reported no difference in days hospitalisation, days treatment or weight gain (low certainty evidence). Opioid versus clonidine: a single study (31 infants) reported no infant with treatment failure in either group. This study did not report seizures, neonatal or infant mortality and neurodevelopmental disability. There was low certainty evidence for no difference in days hospitalisation or days treatment. This study did not report adverse events. Opioid versus diazepam: there was a reduction in treatment failure from use of an opioid (RR 0.43, 95% CI 0.23 to 0.80; 2 studies, 86 infants; low certainty evidence). Seizures, neonatal or infant mortality and neurodevelopmental disability were not reported. A single study of 34 infants comparing methadone versus diazepam reported no difference in days hospitalisation or days treatment (very low certainty evidence). Adverse events were not reported. Opioid versus phenobarbital: there was a reduction in treatment failure from use of an opioid (RR 0.51, 95% CI 0.35 to 0.74; 6 studies, 458 infants; moderate certainty evidence). Subgroup analysis found a reduction in treatment failure in trials titrating morphine to ≧ 0.5 mg/kg/day (RR 0.21, 95% CI 0.10 to 0.45; 3 studies, 230 infants), whereas a single study using morphine < 0.5 mg/kg/day reported no difference compared to use of phenobarbital (subgroup difference P = 0.05). Neonatal or infant mortality and neurodevelopmental disability were not reported. A single study (111 infants) of paregoric versus phenobarbital reported seven infants with seizures in the phenobarbital group, whereas no seizures were reported in two studies (170 infants) comparing morphine to phenobarbital. There was no difference in days hospitalisation or days treatment. A single study (96 infants) reported no adverse events in either group. Opioid versus chlorpromazine: there was a reduction in treatment failure from use of morphine versus chlorpromazine (RR 0.08, 95% CI 0.01 to 0.62; 1 study, 90 infants; moderate certainty evidence). No seizures were reported in either group. There was low certainty evidence for no difference in days treatment. This trial reported no adverse events in either group. None of the included studies reported time to control of NAS. Data for duration and severity of NAS were limited, and we were unable to use these data in quantitative synthesis. AUTHORS' CONCLUSIONS Compared to supportive care alone, the addition of an opioid may increase duration of hospitalisation and treatment, but may reduce days to regain birthweight and the duration of supportive care each day. Use of an opioid may reduce treatment failure compared to phenobarbital, diazepam or chlorpromazine. Use of an opioid may have little or no effect on duration of hospitalisation or treatment compared to use of phenobarbital, diazepam or chlorpromazine. The type of opioid used may have little or no effect on the treatment failure rate. Use of buprenorphine probably reduces duration of hospitalisation and treatment compared to morphine, but there are no data for time to control NAS with buprenorphine, and insufficient evidence to determine safety. There is insufficient evidence to determine the effectiveness and safety of clonidine.
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Affiliation(s)
- Angelika Zankl
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
- Central Clinical School, School of Medicine, The University of Sydney, Sydney, Australia
| | - Jill Martin
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Jane G Davey
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
| | - David A Osborn
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
- Central Clinical School, School of Medicine, The University of Sydney, Sydney, Australia
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16
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Harper LM. Telehealth Approaches to Improve Opioid Use Care in Pregnancy. Clin Obstet Gynecol 2021; 64:352-365. [PMID: 33882519 DOI: 10.1097/grf.0000000000000607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Although pharmacotherapy is the mainstay of treatment for opioid use disorder, the US faces a shortage of qualified pharmacotherapy providers, even in high-need areas. Telemedicine is a promising method of increasing the availability of opioid use disorder treatments, but several barriers must first be addressed before implementation. This article presents a case study of using telemedicine to provide pharmacotherapy in pregnancy, examines the barriers to providing pharmacotherapy via telemedicine, and proposes solutions to overcome these barriers.
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Affiliation(s)
- Lorie M Harper
- Department of Women's Health, University of Texas at Austin, Dell Medical School, Austin, Texas
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17
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Multilevel factors associated with length of stay for neonatal abstinence syndrome in Florida's NICUs: 2010-2015. J Perinatol 2021; 41:1389-1396. [PMID: 32939026 DOI: 10.1038/s41372-020-00815-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/13/2020] [Accepted: 09/04/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To investigate potential factors influencing initial length of hospital stay (LOS) for infants with neonatal abstinence syndrome (NAS) in Florida. METHODS The study population included 2984 term, singleton live births in 33 Florida hospitals. We used hierarchical linear modeling to evaluate the association of community, hospital, and individual factors with LOS. RESULTS The average LOS of infants diagnosed with NAS varied significantly across hospitals. Individual-level factors associated with increased LOS for NAS included event year (P < 0.001), gestational age at birth (P < 0.001), maternal age (P = 0.002), maternal race and ethnicity (P < 0.001), maternal education (P = 0.032), and prenatal care adequacy (P < 0.001). Average annual hospital NAS volume (P = 0.022) was a significant hospital factor. CONCLUSION NAS varies widely across hospitals in Florida. In addition to focusing on treatment regimens, to reduce LOS, public health and quality improvement initiatives should identify and adopt strategies that can minimize the prevalence and impact of these contributing factors.
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18
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Ponder KL, Egesdal C, Kuller J, Joe P. Project Console: a quality improvement initiative for neonatal abstinence syndrome in a children's hospital level IV neonatal intensive care unit. BMJ Open Qual 2021; 10:bmjoq-2020-001079. [PMID: 33941537 PMCID: PMC8098972 DOI: 10.1136/bmjoq-2020-001079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 04/10/2021] [Accepted: 04/19/2021] [Indexed: 12/04/2022] Open
Abstract
Objective To improve care for infants with neonatal abstinence syndrome. Design Infants with a gestational age of ≥35 weeks with prenatal opioid exposure were eligible for our quality improvement initiative. Interventions in our Plan–Do–Study–Act cycles included physician consensus, re-emphasis on non-pharmacological treatment, the Eat Sleep Console method to measure functional impairment, morphine as needed, clonidine and alternative soothing methods for parental unavailability (volunteer cuddlers and automated sleeper beds). Pre-intervention and post-intervention outcomes were compared. Results Length of stay decreased from 31.8 to 10.5 days (p<0.0001) without an increase in readmissions. Composite pharmacotherapy exposure days decreased from 28.7 to 5.5 (p<0.0001). This included reductions in both morphine exposure days (p<0.0001) and clonidine exposure days (p=0.01). Fewer infants required pharmacotherapy (p=0.02). Conclusions Our study demonstrates how a comprehensive initiative can improve care for infants with neonatal abstinence syndrome in an open-bay or a high-acuity neonatal intensive care unit when rooming-in is not available or other comorbidities are present.
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Affiliation(s)
- Kathryn L Ponder
- Neonatology, UCSF Benioff Children's Hospital Oakland, Oakland, California, USA
| | - Charles Egesdal
- Pediatrics, UCSF Benioff Children's Hospital Oakland, Oakland, California, USA
| | - Joanne Kuller
- Neonatology, UCSF Benioff Children's Hospital Oakland, Oakland, California, USA
| | - Priscilla Joe
- Neonatology, UCSF Benioff Children's Hospital Oakland, Oakland, California, USA
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19
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Braun D, Edwards EM, Schulman J, Profit J, Pursley DM, Goodman DC. Choosing wisely for the other 80%: What we need to know about the more mature newborn and NICU care. Semin Perinatol 2021; 45:151395. [PMID: 33573773 DOI: 10.1016/j.semperi.2021.151395] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although neonatal intensive unit (NICU) care is envisioned as the care of very immature infants, more than 95% of births and 80% of NICU admissions are of more mature newborns-infants born at 34 or more weeks' gestation. In spite of the size of this population there are important gaps in the understanding of their needs and optimal management as reflected by remarkably large unexplained variation in their care. The goal of this article is to describe what is known about the more mature, higher birth weight newborn population's use of NICU care and highlight important gaps in knowledge and obstacles to research. Research priorities are identified: including (1) the need for birth population based rather than NICU based studies, and (2) population specific data elements. Summary: More mature newborns-infants of 34 or more weeks' gestation-account for most NICU admissions. There are large gaps in the understanding of their needs and optimal management as reflected by large unexplained variation in their care. We enumerate these gaps in current knowledge and suggest research priorities to address them.
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Affiliation(s)
- David Braun
- Neonatal Medicine, Kaiser Permanente, Panorama City, CA, United States; Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States.
| | - Erika M Edwards
- Dept of Pediatrics and Mathematics and Statistics, University of Vermont, Burlington, VT, United States; Vermont Oxford Network, Burlington, VT, United States
| | - Joseph Schulman
- California Department of Health Care Services, California Children's Services, Sacramento, CA, United States
| | - Jochen Profit
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States
| | - DeWayne M Pursley
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA, United States; Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - David C Goodman
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, NH, Lebanon
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20
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Merhar SL, Ounpraseuth S, Devlin LA, Poindexter BB, Young LW, Berkey SD, Crowley M, Czynski AJ, Kiefer AS, Whalen BL, Das A, Fuller JF, Higgins RD, Thombre V, Lester BM, Smith PB, Newman S, Sánchez PJ, Smith MC, Simon AE. Phenobarbital and Clonidine as Secondary Medications for Neonatal Opioid Withdrawal Syndrome. Pediatrics 2021; 147:e2020017830. [PMID: 33632932 PMCID: PMC7919109 DOI: 10.1542/peds.2020-017830] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/04/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Despite the neonatal opioid withdrawal syndrome (NOWS) epidemic in the United States, evidence is limited for pharmacologic management when first-line opioid medications fail to control symptoms. The objective with this study was to evaluate outcomes of infants receiving secondary therapy with phenobarbital compared with clonidine, in combination with morphine, for the treatment of NOWS. METHODS We performed a retrospective cohort study of infants with NOWS from 30 hospitals. The primary outcome measures were the length of hospital stay, duration of opioid treatment, and peak morphine dose. Outcomes were compared by group by using analysis of variance and multivariable linear regression controlling for relevant confounders. RESULTS Of 563 infants with NOWS treated with morphine, 32% (n = 180) also received a secondary medication. Seventy-two received phenobarbital and 108 received clonidine. After adjustment for covariates, length of hospital stay was 10 days shorter, and, in some models, duration of morphine treatment was 7.5 days shorter in infants receiving phenobarbital compared with those receiving clonidine, with no difference in peak morphine dose. Infants were more likely to be discharged from the hospital on phenobarbital than clonidine (78% vs 29%, P < .0001). CONCLUSIONS Among infants with NOWS receiving morphine and secondary therapy, those treated with phenobarbital had shorter length of hospital stay and shorter morphine treatment duration than clonidine-treated infants but were discharged from the hospital more often on secondary medication. Further investigation is warranted to determine if the benefits of shorter hospital stay and shorter duration of morphine therapy justify the possible neurodevelopmental consequences of phenobarbital use in infants with NOWS.
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Affiliation(s)
- Stephanie L Merhar
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio and Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio;
| | - Songthip Ounpraseuth
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Lori A Devlin
- Department of Pediatrics, University of Louisville, Louisville, Kentucky
| | - Brenda B Poindexter
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio and Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Leslie W Young
- Larner College of Medicine at the University of Vermont, Burlington, Vermont
| | - Sean D Berkey
- Alaska Native Tribal Health Consortium, Anchorage, Alaska
| | - Moira Crowley
- Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Adam J Czynski
- Department of Pediatrics, Women and Infant's Hospital, Providence, Rhode Island
| | - Autumn S Kiefer
- Department of Pediatrics, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Bonny L Whalen
- Children's Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Abhik Das
- RTI International, Rockville, Maryland
| | - Janell F Fuller
- University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Rosemary D Higgins
- National Institute of Child Health and Human Development, Bethesda, Maryland and George Mason University, Fairfax, Virginia
| | - Vaishali Thombre
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Barry M Lester
- Center for the Study of Children at Risk, Department of Pediatrics, Brown Alpert Medical School and Women and Infants Hospital, Providence, Rhode Island
| | - P Brian Smith
- Duke Clinical Research Institute, School of Medicine, Duke University, Durham, North Carolina
| | | | - Pablo J Sánchez
- Nationwide Children's Hospital, College of Medicine, The Ohio State University, Columbus, Ohio
| | - M Cody Smith
- Department of Pediatrics, School of Medicine, West Virginia University, Morgantown, West Virginia; and
| | - Alan E Simon
- Environmental Influences on Child Health Outcomes Program, Office of the Director, National Institutes of Health, Rockville, Maryland
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21
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Young LW, Hu Z, Annett RD, Das A, Fuller JF, Higgins RD, Lester BM, Merhar SL, Simon AE, Ounpraseuth S, Smith PB, Crawford MM, Atz AM, Cottrell LE, Czynski AJ, Newman S, Paul DA, Sánchez PJ, Semmens EO, Smith MC, Turley CB, Whalen BL, Poindexter BB, Snowden JN, Devlin LA. Site-Level Variation in the Characteristics and Care of Infants With Neonatal Opioid Withdrawal. Pediatrics 2021; 147:e2020008839. [PMID: 33386337 PMCID: PMC7780957 DOI: 10.1542/peds.2020-008839] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Variation in pediatric medical care is common and contributes to differences in patient outcomes. Site-to-site variation in the characteristics and care of infants with neonatal opioid withdrawal syndrome (NOWS) has yet to be quantified. Our objective was to describe site-to-site variation in maternal-infant characteristics, infant management, and outcomes for infants with NOWS. METHODS Cross-sectional study of 1377 infants born between July 1, 2016, and June 30, 2017, who were ≥36 weeks' gestation, with NOWS (evidence of opioid exposure and NOWS scoring within the first 120 hours of life) born at or transferred to 1 of 30 participating hospitals nationwide. Site-to-site variation for each parameter within the 3 domains was measured as the range of individual site-level means, medians, or proportions. RESULTS Sites varied widely in the proportion of infants whose mothers received adequate prenatal care (31.3%-100%), medication-assisted treatment (5.9%-100%), and prenatal counseling (1.9%-75.5%). Sites varied in the proportion of infants with toxicology screening (50%-100%) and proportion of infants receiving pharmacologic therapy (6.7%-100%), secondary medications (1.1%-69.2%), and nonpharmacologic interventions including fortified feeds (2.9%-90%) and maternal breast milk (22.2%-83.3%). The mean length of stay varied across sites (2-28.8 days), as did the proportion of infants discharged with their parents (33.3%-91.1%). CONCLUSIONS Considerable site-to-site variation exists in all 3 domains. The magnitude of the observed variation makes it unlikely that all infants are receiving efficient and effective care for NOWS. This variation should be considered in future clinical trial development, practice implementation, and policy development.
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Affiliation(s)
- Leslie W Young
- Department of Pediatrics, The Robert Larner, M.D. College of Medicine, The University of Vermont, Burlington, Vermont;
| | | | - Robert D Annett
- Department of Pediatrics, Medical Center, University of Mississippi, Jackson, Mississippi
| | - Abhik Das
- Research Triangle Institute International, Rockville, Maryland
| | - Janell F Fuller
- Health Sciences Center, The University of New Mexico, Albuquerque, New Mexico
| | - Rosemary D Higgins
- National Institute of Child Health and Human Development, Bethesda, Maryland
- College of Health and Human Services, George Mason University, Fairfax, Virginia
| | - Barry M Lester
- Department of Pediatrics and Center for the Study of Children at Risk, Warren Alpert Medical School, Brown University and
| | - Stephanie L Merhar
- Division of Neonatology and Perinatal Institute and
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Alan E Simon
- Environmental Influences on Child Health Outcomes Program and Office of the Director, National Institutes of Health, Rockville, Maryland
| | | | - P Brian Smith
- Duke Clinical Research Institute, School of Medicine, Duke University, Durham, North Carolina;
| | | | - Andrew M Atz
- Department of Pediatrics, College of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Lesley E Cottrell
- Department of Pediatrics, School of Medicine, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown, West Virginia
| | - Adam J Czynski
- Department of Pediatrics, Women and Infants Hospital, Providence, Rhode Island
| | | | - David A Paul
- Division of Neonatology, Department of Pediatrics, ChristianaCare, Newark, Delaware
| | - Pablo J Sánchez
- Nationwide Children's Hospital and College of Medicine, The Ohio State University, Columbus, Ohio
| | - Erin O Semmens
- School of Public and Community Health Sciences, University of Montana, Missoula, Montana
| | - M Cody Smith
- Department of Pediatrics, School of Medicine, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown, West Virginia;
| | - Christine B Turley
- Department of Pediatrics, School of Medicine, University of South Carolina, Columbia, South Carolina
| | - Bonny L Whalen
- Children's Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; and
| | | | - Jessica N Snowden
- Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Lori A Devlin
- Department of Pediatrics, School of Medicine, University of Louisville, Louisville, Kentucky
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22
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Kushnir A, Garretson C, Mariappan M, Stahl G. Use of Phenobarbital to Treat Neonatal Abstinence Syndrome From Exposure to Single vs. Multiple Substances. Front Pediatr 2021; 9:752854. [PMID: 35174112 PMCID: PMC8841756 DOI: 10.3389/fped.2021.752854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 12/21/2021] [Indexed: 11/17/2022] Open
Abstract
Drug use in pregnancy is a major public health issue. Intrauterine exposure to opioids alone or in addition to other substances may lead to neonatal abstinence syndrome (NAS). Little consensus exists on optimal therapy, especially for those exposed to multiple drugs. We aim to determine whether the use of opioids alone vs. in combination with phenobarbital will affect short-term neonatal outcomes. This retrospective review of infants admitted to the neonatal intensive care unit (NICU) included newborns ≥35 weeks of gestation exposed to opioids, or multiple substances including opioids, in utero. Treatment with opioids alone, and addition of phenobarbital as initial therapy vs. rescue, was evaluated. Out of 182 newborns, 54 (30%) were exposed to methadone alone vs. 128 (70%) to multiple drugs. Length of stay (LOS) in the hospital was not significantly affected (p = 0.684) by single vs. multiple drug exposure in utero. Treatment of NAS with opioid alone resulted in significantly shorter LOS (27 days), as compared to those treated with opioid and phenobarbital (45 days, p < 0.001). LOS was further prolonged in those treated with phenobarbital as a "rescue" medication in addition to an opioid (49 days, p < 0.0001). There was a significant increase in LOS and duration of opioid treatment for all infants treated with phenobarbital, both in those exposed to opioids alone, and to multiple substances in utero.
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Affiliation(s)
- Alla Kushnir
- Division of Neonatology, Department of Pediatric, Cooper University Hospital, Camden, NJ, United States.,Department of Pediatric, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Cynthia Garretson
- Ambulatory Clinical Practice, Cooper University Hospital, Cherry Hill, NJ, United States
| | - Maheswari Mariappan
- Division of Neonatology, Department of Pediatric, Cooper University Hospital, Camden, NJ, United States
| | - Gary Stahl
- Department of Pediatric, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States
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Wijekoon N, Aduroja O, Biggs JM, El-Metwally D, Gopalakrishnan M. Model-Based Approach to Improve Clinical Outcomes in Neonates With Opioid Withdrawal Syndrome Using Real-World Data. Clin Pharmacol Ther 2020; 109:243-252. [PMID: 33119888 DOI: 10.1002/cpt.2093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 10/11/2020] [Indexed: 12/13/2022]
Abstract
At least 60% of the neonates with opioid withdrawal syndrome (NOWS) require morphine to control withdrawal symptoms. Currently, the morphine dosing strategies are empiric, not optimal and associated with longer hospital stay. The aim of the study was to develop a quantitative, model-based, real-world data-driven approach to morphine dosing to improve clinical outcomes, such as reducing time on treatment. Longitudinal morphine dose, clinical response (Modified Finnegan Score (MFS)), and baseline risk factors were collected using a retrospective cohort design from the electronic medical records of neonates with NOWS (N = 177) admitted to the University of Maryland Medical Center. A dynamic linear mixed effects model was developed to describe the relationship between MFS and morphine dose adjusting for baseline risk factors using a split-sample data approach (70% training: 30% test). The training model was evaluated in the test dataset using a simulation based approach. Maternal methadone and benzodiazepine use, and race were significant predictors of the MFS response. Positive autocorrelations of 0.56 and 0.12 were estimated between consecutive MFS responses. On an average, for a 1,000 μg increase in the morphine dose, the MFS decreased by 0.3 units. The model evaluation showed that observed and predicted median time on treatment were similar (13.0 vs. 13.8 days). A model-based framework was developed to describe the MFS-morphine dose relationship using real-world data that could potentially be used to develop an adaptive, individualized morphine dosing strategy to improve clinical outcomes in infants with NOWS.
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Affiliation(s)
- Nadeesri Wijekoon
- Department of Mathematics and Statistics, University of Maryland, Baltimore County, Baltimore, Maryland, USA
| | - Oluwatobi Aduroja
- Department of Pediatrics, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Jessica M Biggs
- University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Dina El-Metwally
- Department of Pediatrics, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Mathangi Gopalakrishnan
- Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
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Abstract
The opioid crisis has grown to affect pregnant women and infants across the United States, as evidenced by rising rates of opioid use disorder among pregnant women and neonatal opioid withdrawal syndrome among infants. Across the country, pregnant women lack access to evidence-based therapies, including medications for opioid use disorder, and infants with opioid exposure frequently receive variable care. In addition, public systems, such as child welfare and early intervention, are increasingly stretched by increasing numbers of children affected by the crisis. Systematic, enduring, coordinated, and holistic approaches are needed to improve care for the mother-infant dyad. In this statement, we provide an overview of the effect of the opioid crisis on the mother-infant dyad and provide recommendations for management of the infant with opioid exposure, including clinical presentation, assessment, treatment, and discharge.
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Affiliation(s)
- Stephen W Patrick
- Division of Neonatology, Department of Pediatrics and Health Policy, School of Medicine, Vanderbilt University and Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee;
| | - Wanda D Barfield
- Centers for Disease Control and Prevention, Atlanta, Georgia; and
| | - Brenda B Poindexter
- Department of Pediatrics, College of Medicine, University of Cincinnati and Cincinnati Children's Medical Hospital Center, Cincinnati, Ohio
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van Hoogdalem MW, McPhail BT, Hahn D, Wexelblatt SL, Akinbi HT, Vinks AA, Mizuno T. Pharmacotherapy of neonatal opioid withdrawal syndrome: a review of pharmacokinetics and pharmacodynamics. Expert Opin Drug Metab Toxicol 2020; 17:87-103. [PMID: 33049155 DOI: 10.1080/17425255.2021.1837112] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Neonatal opioid withdrawal syndrome (NOWS) often arises in infants born to mothers who used opioids during pregnancy. Morphine, methadone, and buprenorphine are the most common first-line treatments, whereas clonidine and phenobarbital are generally reserved for adjunctive therapy. These drugs exhibit substantial pharmacokinetic (PK) and pharmacodynamic (PD) variability. Current pharmacological treatments for NOWS are based on institutional protocols and largely rely on empirical treatment of patient symptoms. AREAS COVERED This article reviews the PK/PD of NOWS pharmacotherapies with a focus on the implication of physiological development and maturation. Body size-standardized clearance is consistently low in neonates, except for methadone. This can be ascribed to underdeveloped metabolic and elimination pathways. The effects of pharmacogenetics have been clarified especially for morphine. The PK/PD relationship of medications used in the treatment of NOWS is generally understudied. EXPERT OPINION Providing an appropriate opioid dose in neonates is challenging. Advancements in quantitative pharmacology and PK/PD modeling approaches facilitate identification of key factors driving PK/PD variability and characterization of exposure-response relationships. PK/PD model-informed simulations have been widely employed to define age-appropriate pediatric dosing regimens. The model-informed approach holds promise to aid more rational use of medications in the treatment of NOWS.
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Affiliation(s)
- Matthijs W van Hoogdalem
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,James L. Winkle College of Pharmacy, University of Cincinnati , Cincinnati, OH, USA
| | - Brooks T McPhail
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,School of Medicine Greenville, University of South Carolina , Greenville, SC, USA
| | - David Hahn
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA
| | - Scott L Wexelblatt
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati , Cincinnati, OH, USA.,Center for Addiction Research, College of Medicine, University of Cincinnati , Cincinnati, OH, USA
| | - Henry T Akinbi
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati , Cincinnati, OH, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati , Cincinnati, OH, USA.,Center for Addiction Research, College of Medicine, University of Cincinnati , Cincinnati, OH, USA
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati , Cincinnati, OH, USA.,Center for Addiction Research, College of Medicine, University of Cincinnati , Cincinnati, OH, USA
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26
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Kaplan HC, Kuhnell P, Walsh MC, Crowley M, McClead R, Wexelblatt S, Ford S, Provost LP, Lannon C, Macaluso M. Orchestrated Testing of Formula Type to Reduce Length of Stay in Neonatal Abstinence Syndrome. Pediatrics 2020; 146:peds.2019-0914. [PMID: 32913133 DOI: 10.1542/peds.2019-0914] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Despite the standardization of care, formula feeding varied across sites of the Ohio Perinatal Quality Collaborative (OPQC). We used orchestrated testing (OT) to learn from this variation and improve nonpharmacologic care of infants with neonatal abstinence syndrome (NAS) requiring pharmacologic treatment in Ohio. METHODS To test the impact of formula on length of stay (LOS), treatment failure, and weight loss among infants hospitalized with NAS, we compared caloric content (high versus standard) and lactose content (low versus standard) using a 22 factorial design. During October 2015 to June 2016, OPQC sites joined 1 of 4 OT groups. We used response plots to examine the effect of each factor and control charts to track formula use and LOS. We used the OT results to revise the nonpharmacologic bundle and implemented it during 2017. RESULTS Forty-seven sites caring for 546 NAS infants self-selected into the 4 OT groups. Response plots revealed the benefit of high-calorie formula (HCF) on weight loss, treatment failure, and LOS. The nonpharmacologic treatment bundle was updated to recommend HCF when breastfeeding was not possible. During implementation, HCF use increased, and LOS decreased from 17.1 to 16.4 days across the OPQC. CONCLUSIONS OT revealed that HCF was associated with shorter LOS in OPQC sites. Implementation of a revised nonpharmacologic care bundle was followed by additional LOS improvement in Ohio. Despite some challenges in the implementation of OT, our findings support its usefulness for learning in improvement networks.
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Affiliation(s)
- Heather C Kaplan
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio; .,Perinatal Institute.,James M. Anderson Center for Health Systems Excellence, and
| | - Pierce Kuhnell
- Division of Epidemiology and Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michele C Walsh
- Division of Neonatology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio.,Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
| | - Moira Crowley
- Division of Neonatology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio.,Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
| | - Richard McClead
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio; and
| | - Scott Wexelblatt
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,Perinatal Institute
| | - Susan Ford
- Division of Neonatology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | | | - Carole Lannon
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,James M. Anderson Center for Health Systems Excellence, and
| | - Maurizio Macaluso
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,Division of Epidemiology and Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Physiologic Indirect Response Modeling to Describe Buprenorphine Pharmacodynamics in Newborns Treated for Neonatal Opioid Withdrawal Syndrome. Clin Pharmacokinet 2020; 60:249-259. [PMID: 32939690 DOI: 10.1007/s40262-020-00939-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND OBJECTIVE Buprenorphine has been shown to be effective in treating infants with neonatal opioid withdrawal syndrome. However, an evidence-based buprenorphine dosing strategy has not been established in the treatment of neonatal opioid withdrawal syndrome because of a lack of exposure-response data. The aim of this study was to develop an integrated pharmacokinetic and pharmacodynamic model to predict buprenorphine treatment outcomes in newborns with neonatal opioid withdrawal syndrome. METHODS Clinical data were obtained from 19 newborns with a median (range) gestational age of 37 (34-41) weeks enrolled in a pilot pharmacokinetic study of buprenorphine. Sparse blood sampling, comprising three specimens obtained around the second dose of buprenorphine, was performed using heel sticks with dried blood spot technology. Standardized neonatal opioid withdrawal syndrome severity scores (Finnegan scores) were collected every 3-4 h based on symptoms by bedside nursing staff. Mean Finnegan scores were used as a pharmacodynamic marker in the exposure-response modeling. The blood concentration-Finnegan score relationship was described using a physiologic indirect response model with inclusion of natural disease remission. RESULTS A total of 52 buprenorphine blood concentrations and 780 mean Finnegan scores were available for the pharmacokinetic/pharmacodynamic modeling and exposure-response analysis. A one-compartment model with first-order absorption adequately described the pharmacokinetic data. The buprenorphine blood concentration at 50% of maximum effect for the inhibition of disease progression was 0.77 ng/mL (95% confidence interval 0.32-1.2). The inclusion of natural disease remission described as a function of postnatal age significantly improved the model fit. CONCLUSIONS A buprenorphine pharmacokinetic/pharmacodynamic model was successfully developed. The model could facilitate model-informed optimization of the buprenorphine dosing regimen in the treatment of neonatal opioid withdrawal syndrome.
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Percy Z, Brokamp C, McAllister JM, Ryan P, Wexelblatt SL, Hall ES. Subclinical and Overt Newborn Opioid Exposure: Prevalence and First-Year Healthcare Utilization. J Pediatr 2020; 222:52-58.e1. [PMID: 32423682 PMCID: PMC7412356 DOI: 10.1016/j.jpeds.2020.03.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/09/2020] [Accepted: 03/20/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To categorize newborn infants in Hamilton County, Ohio by late pregnancy fetal opioid exposure status and to assess their first-year healthcare utilization. STUDY DESIGN We used a population-based cohort of 41 136 live births from 2014-2017 and analyzed healthcare encounters in the first year of life from electronic health records. We prospectively assessed for the presence of opioids in maternal urine collected at delivery and for a diagnosis of newborn neonatal abstinence syndrome (NAS). At birth, infants were classified as unexposed to opioids, exposed to opioids and diagnosed with NAS, or subclinically exposed to opioids (exposure that did not result in NAS). RESULTS The prevalence of newborn opioid exposure was 37 per 1000 births. The duration of the hospital birth encounter was significantly longer for infants with subclinical exposure compared with unexposed infants (10% increase; 95% CI, 7%-13%). However, duration for infants with subclinical exposure was shorter compared to those with NAS. Neither subclinical exposure nor NAS was associated with total emergency department visits. Subclinical exposure was associated with increased odds of having at least 1 hospitalization in the first year. However, the total length of stay for hospitalizations was 82% that of the unexposed group (95% CI, 75%-89%). Infants with NAS had a 213% longer total length of stay compared with the unexposed group (95% CI, 191%-237%). CONCLUSIONS Subclinical and overt opioid exposure among newborn infants was associated with increased first-year healthcare utilization. From 2014 to 2017, this cost the Hamilton County healthcare system an estimated $1 109 452 for longer birth encounters alone.
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Affiliation(s)
- Zana Percy
- Medical Scientist Training Program, University of Cincinnati College of Medicine, Cincinnati, Ohio,Department of Environmental Health, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Cole Brokamp
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jennifer M. McAllister
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio,Perinatal Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Patrick Ryan
- Department of Environmental Health, University of Cincinnati College of Medicine, Cincinnati, Ohio,Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Scott L. Wexelblatt
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio,Perinatal Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Eric S. Hall
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio,Perinatal Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
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29
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Devlin LA, Breeze JL, Terrin N, Gomez Pomar E, Bada H, Finnegan LP, O’Grady KE, Jones HE, Lester B, Davis JM. Association of a Simplified Finnegan Neonatal Abstinence Scoring Tool With the Need for Pharmacologic Treatment for Neonatal Abstinence Syndrome. JAMA Netw Open 2020; 3:e202275. [PMID: 32267513 PMCID: PMC7142377 DOI: 10.1001/jamanetworkopen.2020.2275] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
IMPORTANCE Observer-rated scales, such as the Finnegan Neonatal Abstinence Scoring Tool (FNAST), are used to quantify the severity of neonatal abstinence syndrome (NAS) and guide pharmacologic therapy. The FNAST, a comprehensive 21-item assessment tool, was developed for research and subsequently integrated into clinical practice; a simpler tool, designed to account for clinically meaningful outcomes, is urgently needed to standardize assessment. OBJECTIVES To identify FNAST items independently associated with the decision to use pharmacologic therapy and to simplify the FNAST while minimizing loss of information for the treatment decision. DESIGN, SETTING, AND PARTICIPANTS This multisite cohort study included 424 neonates with opioid exposure who had a gestational age of at least 36 weeks with follow-up from birth to hospital discharge in the derivation cohort and 109 neonates with opioid exposure from the Maternal Opioid Treatment: Human Experimental Research Study in the validation cohort. Neonates in the derivation cohort were included in a medical record review at the Universities of Louisville and Kentucky or in a randomized clinical trial and observational study conducted at Tufts University (2014-2018); the Maternal Opioid Treatment: Human Experimental Research was conducted from 2005 to 2008. Data analysis was conducted from May 2017 to August 2019. EXPOSURES Prenatal opioid exposure. MAIN OUTCOMES AND MEASURES All FNAST items were dichotomized as present or not present, and logistic regression was used to identify binary items independently associated with pharmacologic treatment. The final model was validated with an independent cohort of neonates with opioid exposure. RESULTS Among 424 neonates (gestational age, ≥36 weeks; 217 [51%] female infants), convulsions were not observed, and high-pitched cry and hyperactive Moro reflex had extremely different frequencies across cohorts. Therefore, these 3 FNAST items were removed from further analysis. The 2 tremor items were combined, and 8 of the remaining 17 items were independently associated with pharmacologic treatment, with an area under the curve of 0.86 (95% CI, 0.82-0.89) compared with 0.90 (95% CI, 0.87-0.94) for the 21-item FNAST. External validation of the 8 items resulted in an area under the curve of 0.86 (95% CI, 0.79-0.93). Thresholds of 4 and 5 on the simplified scale yielded the closest agreement with FNAST thresholds of 8 and 12 (weighted κ = 0.55; 95% CI, 0.48-0.61). CONCLUSIONS AND RELEVANCE The findings of this study suggest that 8 signs of NAS may be sufficient to assess whether a neonate meets criteria for pharmacologic therapy. A focus on these signs could simplify the FNAST tool and may enhance its clinical utility.
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Affiliation(s)
- Lori A. Devlin
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky
| | - Janis L. Breeze
- Tufts Clinical and Translational Science Institute, Boston, Massachusetts
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Norma Terrin
- Tufts Clinical and Translational Science Institute, Boston, Massachusetts
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | | | | | | | | | | | - Barry Lester
- Women and Infants Hospital, Providence, Rhode Island
| | - Jonathan M. Davis
- Tufts Clinical and Translational Science Institute, Boston, Massachusetts
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
- The Floating Hospital for Children at Tufts Medical Center, Boston, Massachusetts
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30
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Shan F, MacVicar S, Allegaert K, Offringa M, Jansson LM, Simpson S, Moulsdale W, Kelly LE. Outcome reporting in neonates experiencing withdrawal following opioid exposure in pregnancy: a systematic review. Trials 2020; 21:262. [PMID: 32164782 PMCID: PMC7069160 DOI: 10.1186/s13063-020-4183-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 02/19/2020] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Flora Shan
- Department of Pediatric and Child Health, University of Manitoba, 405 Chown, 753 McDermot Ave., Winnipeg, MB, R3E0T6, Canada
| | - Sonya MacVicar
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Karel Allegaert
- Department of Development and Regeneration, and Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Department of Clinical Pharmacy, Erasmus MC, Rotterdam, The Netherlands
| | - Martin Offringa
- Department of Paediatrics, University of Toronto, Child Health Evaluative Services, The Hospital of Sick Children, Toronto, Canada
| | - Lauren M Jansson
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sarah Simpson
- Special Care Nursery, Women's and Infants' Program, St. Joseph's Healthcare, Hamilton, Canada
| | - Wendy Moulsdale
- Dan Centre for Women and Babies, Neonatal Intensive Care Unit, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Lauren E Kelly
- Department of Pediatric and Child Health, University of Manitoba, 405 Chown, 753 McDermot Ave., Winnipeg, MB, R3E0T6, Canada. .,Clinical Trials Platform, the George and Fay Yee Centre for Healthcare innovation, Winnipeg, Canada.
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31
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Managing Abstinence in Newborns (MAiN): Redesigning NAS care for the mother/baby unit. Healthcare (Basel) 2020; 8:100404. [DOI: 10.1016/j.hjdsi.2019.100404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 11/07/2019] [Accepted: 11/26/2019] [Indexed: 11/17/2022] Open
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Clemans-Cope L, Holla N, Lee HC, Cong AS, Castro R, Chyi L, Huang A, Taylor KJ, Kenney GM. Neonatal abstinence syndrome management in California birth hospitals: results of a statewide survey. J Perinatol 2020; 40:463-472. [PMID: 31911649 PMCID: PMC7042156 DOI: 10.1038/s41372-019-0568-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 11/22/2019] [Accepted: 12/18/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Assess management of neonatal abstinence syndrome (NAS) in California hospitals to identify potential opportunities to expand the use of best practices. STUDY DESIGN We fielded an internet-based survey of 37 questions to medical directors or nurse managers at 145 birth hospitals in California. RESULTS Seventy-five participants (52%) responded. Most respondents reported having at least one written protocol for managing NAS, but gaps included protocols for pharmacologic management. Newer tools for assessing NAS severity were not commonly used. About half reported usually or always using nonpharmacologic strategies; there is scope for increasing breastfeeding when recommended, skin-to-skin care, and rooming-in. CONCLUSIONS We found systematic gaps in care for infants with NAS in a sample of California birth hospitals, as well as opportunities to spread best practices. Adoption of new approaches will vary across hospitals. A concerted statewide effort to facilitate such implementation has strong potential to increase access to evidence-based treatment for infants and mothers.
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Affiliation(s)
- Lisa Clemans-Cope
- The Urban Institute, 500 L'Enfant Plaza SW, Washington, DC, 20037, USA.
| | - Nikhil Holla
- George Washington University, Washington, DC, USA
| | - Henry C Lee
- Division of Neonatal & Developmental Medicine, Stanford University, Stanford, CA, USA
| | - Allison Shufei Cong
- California Perinatal Quality Care Collaborative (CPQCC), Stanford University, Stanford, CA, USA
| | - Robert Castro
- Division of Neonatal & Developmental Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Lisa Chyi
- Walnut Creek Medical Center, Kaiser Northern California NAS Workgroup Co-chair, Walnut Creek, CA, USA
| | - Angela Huang
- Department of Neonatology, Santa Clara Valley Medical Center, San Jose, CA, USA
| | - Kimá Joy Taylor
- The Urban Institute, 500 L'Enfant Plaza SW, Washington, DC, 20037, USA
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Burduli E, Smith CL, Tham P, Shogan M, Johnson RK, McPherson SM. Development and application of a primer and reference assessment tool for neonatal abstinence syndrome: A phase I pilot study. Contemp Clin Trials Commun 2019; 17:100494. [PMID: 31867467 PMCID: PMC6906735 DOI: 10.1016/j.conctc.2019.100494] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 11/04/2019] [Accepted: 11/17/2019] [Indexed: 11/01/2022] Open
Abstract
Background Despite evidence for the efficacy of strict neonatal abstinence syndrome (NAS) treatment protocols, no national standardized education, diagnosis or treatment strategy is available. Objectives To describe the development and preliminary usability of an electronic bedside primer and decision support tool for medical providers, with embedded, interactive education and reference modules. Methods A panel of NAS experts established a standard operating procedure for the best practices of NAS management and developed an interactive mobile primer and reference and assessment tool to assess NAS with a curriculum and decision support system. We tested the feasibility and usability of this tool with n = 8 users, including registered nurses, last-year undergraduate nursing students and neonatal physicians. Results Participants rated the usability of the modules positively, with an average rating of 4.5 (scale of "1 = Strongly disagree" to "5 = Strongly agree"). Participants appreciated the ability to score the infant at the bedside using real time electronic entry. Seven users noted that the electronic device entry would be as accurate as paper or computer-based Electronic Medical Records entry and one user indicated it would potentially be more accurate during post-usability interviews. Users recommended improvements to the curriculum, including increasing detail of definitions and adding videos for additional NAS signs. Conclusion The assessment tool appears to be acceptable and usable by potential users. The strong ratings across users provides support for further testing whether its acceptability and usability remain high in a hospital setting, while assessing the impact on clinical outcomes such as newborn hospital length of stay.
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Affiliation(s)
- Ekaterina Burduli
- College of Nursing, Washington State University, Spokane, WA, 99210-1495, USA.,Analytics and PsychoPharmacology Laboratory (APPL) and the Program of Excellence in Addictions Research (PEAR), Washington State University, Spokane, WA, 99210-1495, USA
| | - Crystal Lederhos Smith
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, 99210-1495, USA.,Analytics and PsychoPharmacology Laboratory (APPL) and the Program of Excellence in Addictions Research (PEAR), Washington State University, Spokane, WA, 99210-1495, USA
| | - Phoebe Tham
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, 99210-1495, USA.,Analytics and PsychoPharmacology Laboratory (APPL) and the Program of Excellence in Addictions Research (PEAR), Washington State University, Spokane, WA, 99210-1495, USA
| | - Maureen Shogan
- College of Nursing, Washington State University, Spokane, WA, 99210-1495, USA.,Ringful Health, LLC, Spokane, WA, 99210, USA
| | | | - Sterling M McPherson
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, 99210-1495, USA.,Analytics and PsychoPharmacology Laboratory (APPL) and the Program of Excellence in Addictions Research (PEAR), Washington State University, Spokane, WA, 99210-1495, USA
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34
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Abstract
BACKGROUND The opioid epidemic in the United States has reached unprecedented proportions with far-reaching impacts on the most vulnerable population. The number of neonates born addicted to opioids has grown exponentially over the last several decades, leading to increased neonatal intensive care unit admissions and rising healthcare costs. Recent studies have yielded mixed results regarding which medication is most effective at relieving the symptoms of opioid withdrawal and reducing the weaning timeframe for babies with neonatal abstinence syndrome (NAS). PURPOSE To explore and compare the effectiveness of morphine versus methadone in the treatment for NAS using a standardized protocol. METHOD A literature search of PubMed and CINAHL was performed. The search yielded 10 quantitative studies that were analyzed for potential practice changes. CONCLUSION Based on current literature, following a standardized, stringent weaning protocol is more beneficial than the pharmacologic agent used. Studies reveal shorter weaning times and hospital stays in almost every group that followed rigid guidelines. IMPLICATION FOR RESEARCH Although current studies are promising for the desired outcome, more research is needed to develop appropriate protocol-based weaning regimens for management of NAS. IMPLICATION FOR PRACTICE As the occurrence of NAS continues to rise, its management must vigorously meet the challenges of the diagnosis. Institutions should reevaluate their current protocols based on reassuring data showing that stringent guidelines using morphine or methadone can improve clinical outcomes, reduce hospital length, and lower healthcare costs.
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Taleghani AA, Isemann BT, Rice WR, Ward LP, Wedig KE, Akinbi HT. Buprenorphine pharmacotherapy for the management of neonatal abstinence syndrome in methadone‐exposed neonates. ACTA ACUST UNITED AC 2019; 1:33-38. [PMID: 35548374 PMCID: PMC8975186 DOI: 10.1002/pne2.12008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 08/28/2019] [Accepted: 09/28/2019] [Indexed: 01/18/2023]
Abstract
We aimed to compare the outcomes of pharmacotherapy with either buprenorphine or methadone in infants treated for neonatal abstinence syndrome (NAS) secondary to intrauterine exposure to methadone. This is a multi‐center, retrospective cohort study to assess length of treatment (LOT), hospital length of stay (LOS), and cumulative opioid exposure between infants treated with either methadone or buprenorphine for NAS secondary to in utero exposure to methadone. Infants delivered at a gestational age ≥35 weeks and a maternal history of opioid‐use disorder and/or urine drug screen positive for methadone, and postnatal pharmacotherapy for NAS with either buprenorphine or methadone as first‐line opioid replacement therapy, were eligible. Median LOT, LOS, and cumulative opioid exposure were compared between buprenorphine‐ and methadone‐treated infants. A total of 156 infants (48 treated with buprenorphine and 108 with methadone) were identified. The median LOT and LOS for buprenorphine‐treated infants was 8 and 13 days compared with 15 and 20 days for methadone‐treated infants, respectively, P < .001 for both outcomes. Median cumulative opioid dose in morphine equivalents was 0.6 mg/kg for buprenorphine‐treated infants vs 1.05 mg/kg for methadone‐treated infants, P < .001. No adverse effects were noted among either group. Of infants treated with buprenorphine, 34 (71%) required the addition of adjunctive pharmacotherapy during the NICU stay, compared with 31 (32%) in the methadone‐treated group, P = .0008. However, significantly fewer infants treated with buprenorphine required continuation of therapy beyond discharge as compared with those treated with methadone. The difference is most likely a reflection of the protocols used by the sites. In infants that required pharmacotherapy for NAS secondary to intrauterine exposure to methadone, treatment with buprenorphine, compared with methadone therapy, was associated with better outcomes. If confirmed with prospective data, buprenorphine could be considered first‐line therapy for the two medication‐assisted treatment regimens recommended by the American College of Obstetricians and Gynecologists.
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Affiliation(s)
- Afshin A. Taleghani
- University of Cincinnati Medical Center Cincinnati Ohio
- James L. Winkle College of Pharmacy University of Cincinnati Cincinnati Ohio
| | - Barbara T. Isemann
- University of Cincinnati Medical Center Cincinnati Ohio
- James L. Winkle College of Pharmacy University of Cincinnati Cincinnati Ohio
| | - Ward R. Rice
- Department of Pediatrics University of Cincinnati Cincinnati Ohio
- Division of Neonatology and Pulmonary Biology Cincinnati Children’s Hospital Medical Center Cincinnati Ohio
- St. Elizabeth Medical Center Edgewood Kentucky
| | - Laura P. Ward
- Department of Pediatrics University of Cincinnati Cincinnati Ohio
- Division of Neonatology and Pulmonary Biology Cincinnati Children’s Hospital Medical Center Cincinnati Ohio
- Mercy Hospital Anderson Cincinnati Ohio
| | - Kathy E. Wedig
- Department of Pediatrics University of Cincinnati Cincinnati Ohio
- Division of Neonatology and Pulmonary Biology Cincinnati Children’s Hospital Medical Center Cincinnati Ohio
- Good Samaritan Hospital Cincinnati Ohio
| | - Henry T. Akinbi
- University of Cincinnati Medical Center Cincinnati Ohio
- Department of Pediatrics University of Cincinnati Cincinnati Ohio
- Division of Neonatology and Pulmonary Biology Cincinnati Children’s Hospital Medical Center Cincinnati Ohio
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Comparative effectiveness of opioid replacement agents for neonatal opioid withdrawal syndrome: a systematic review and meta-analysis. J Perinatol 2019; 39:1535-1545. [PMID: 31316147 PMCID: PMC7784556 DOI: 10.1038/s41372-019-0437-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 05/22/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE(S) To compare short-term treatment outcomes of opioid pharmacotherapy for neonatal opioid withdrawal syndrome (NOWS). STUDY DESIGN PubMed/MEDLINE, Embase, PsycINFO, and The Cochrane Library were searched from inception through September 30, 2018. Primary outcome was treatment duration (LOT). Secondary outcomes included hospitalization duration (LOS) and rate of adjunct drug needed (RAD). RESULTS Of 753 publications, 11 studies met inclusion criteria. There was no difference in LOT (WMD -1.39 [-5.79 to -3.01] days, I2 82%) or LOS (WMD -1.48 [-5.75 to -2.79] days, I2 92%) between morphine and methadone. RAD with morphine was higher (RR 1.51 [1.35-1.69], I2 0%). Buprenorphine was associated with shorter LOT (WMD 7.70 [0.88-14.53] days, I2 76%) and LOS (WMD 5.61 [-0.01 to -11.24] days, I2 60%) compared with morphine, in addition to methadone according to two cohort studies. CONCLUSIONS Methadone had superior primary treatment success compared with morphine. Buprenorphine was associated with the shortest overall durations of treatment and hospitalization.
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37
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Xiao F, Yan K, Zhou W. Methadone versus morphine treatment outcomes in neonatal abstinence syndrome: A meta-analysis. J Paediatr Child Health 2019; 55:1177-1182. [PMID: 31479559 DOI: 10.1111/jpc.14609] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 06/28/2019] [Accepted: 08/11/2019] [Indexed: 12/26/2022]
Abstract
AIM To determine whether morphine has better outcomes for neonatal abstinence syndrome treatment than methadone. METHODS Studies published before 1 January 2019 were identified using the PubMed, Web of Science, Scopus, Cochrane Library and ClinicalTrials.gov databases. The Cochrane Collaboration Risk of Bias Tool was used to assess the risk of bias for randomised clinical trials. In addition, the risk of bias for non-randomised studies was evaluated by a non-randomised studies of interventions tool. RESULTS We identified 1020 published studies, and 5 were included in the final analysis. Results showed no significant difference in opioid treatment days (standardised mean difference (SMD) = 0.32, 95% confidence interval (CI) = -0.16, 0.80), length of hospital stay (SMD = -0.33, 95% CI = -1.21, 0.56) and duration of treatment (SMD = -0.83 95% CI = -2.09, 0.43) between morphine or methadone treatment. CONCLUSIONS Our meta-analysis of current evidence demonstrated that neonatal abstinence syndrome treatment with morphine was not associated with better outcomes in infants compared with methadone treatment.
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Affiliation(s)
- Feifan Xiao
- Children's Hospital and Institutes of Biomedical Sciences, Division of Neonatology, Children's Hospital of Fudan University, Shanghai, China.,Institute of Biomedical Sciences, Fudan University, Shanghai, China
| | - Kai Yan
- Children's Hospital and Institutes of Biomedical Sciences, Division of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Wenhao Zhou
- Children's Hospital and Institutes of Biomedical Sciences, Division of Neonatology, Children's Hospital of Fudan University, Shanghai, China
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38
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Larson JJ, Graham DL, Singer LT, Beckwith AM, Terplan M, Davis JM, Martinez J, Bada HS. Cognitive and Behavioral Impact on Children Exposed to Opioids During Pregnancy. Pediatrics 2019; 144:peds.2019-0514. [PMID: 31320466 PMCID: PMC10106099 DOI: 10.1542/peds.2019-0514] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2019] [Indexed: 11/24/2022] Open
Abstract
The developmental impact of opioid use during pregnancy is a subject of ongoing debate. Short-term neonatal outcomes, such as lower birth weight and neonatal abstinence syndrome, are the most well-recognized outcomes. However, knowledge gaps exist regarding longer-term neurocognitive and mental health outcomes. In this article, we summarize an expert panel discussion that was held in April 2018 by the Substance Abuse and Mental Health Services Administration and attended by national experts in the field of perinatal opioid exposure and its impact on child development. Despite the challenges with research in this area, there is emerging literature revealing an association between neonates exposed to opioids in utero and longer-term adverse neurocognitive, behavioral, and developmental outcomes. Although adverse sequalae may not be apparent in the neonatal period, they may become more salient as children develop and reach preschool and school age. Multiple variables (genetic, environmental, and biological) result in a highly complex picture. The next steps and strategies to support families impacted by opioid use disorder are explored. Model programs are also considered, including integrated care for the child and mother, parenting supports, and augmentations to home visiting.
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Affiliation(s)
- Justine J Larson
- Substance Abuse and Mental Health Services Administration, Rockville, Maryland;
| | - Devon L Graham
- College of Medicine, Florida State University, Tallahassee, Florida
| | | | | | - Mishka Terplan
- School of Medicine, Tufts University, Boston, Massachusetts
| | | | - Juan Martinez
- School of Public Health, University of Colorado Denver, Denver, Colorado; and
| | - Henrietta S Bada
- College of Medicine, University of Kentucky, Lexington, Kentucky
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39
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Snowden JN, Akshatha A, Annett RD, Crawford MM, Das A, Devlin LA, Higgins RD, Hu Z, Lindsay E, Merhar S, Campbell Nesmith C, Pratt-Chavez H, Ross J, Simon AE, Smith MC, Turley CB, Walden A, Young L, Whalen B. The ACT NOW Clinical Practice Survey: Gaps in the Care of Infants With Neonatal Opioid Withdrawal Syndrome. Hosp Pediatr 2019; 9:585-592. [PMID: 31324654 DOI: 10.1542/hpeds.2019-0089] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES The incidence of neonatal opioid withdrawal syndrome (NOWS) has increased fivefold over the last 10 years. Standardized NOWS care protocols have revealed many improved patient outcomes. Our objective for this study is to describe results of a clinical practice survey of NOWS management practices designed to inform future clinical studies in the diagnosis and management of NOWS. METHODS A cross-sectional survey was administered to medical unit directors at 32 Institutional Development Award States Pediatric Clinical Trial Network and 22 Neonatal Research Network sites in the fall of 2017. Results are presented as both the number and percentage of positive responses. Ninety-five percent Wilson confidence intervals (CIs) were generated around estimates, and χ2 and Fisher's exact tests were used to compare the association between unit type and reporting of each protocol. RESULTS Sixty-two responses representing 54 medical centers were received. Most participating NICU and non-ICU sites reported protocols for NOWS management, including NOWS scoring (98% NICU; 86% non-ICU), pharmacologic treatment (92% NICU; 64% non-ICU), and nonpharmacologic care (79% NICU; 79% non-ICU). Standardized protocols for pharmacologic care and weaning were reported more frequently in the NICU (92% [95% CI: 80%-97%] and 94% [95% CI: 83%-98%], respectively) compared with non-ICU settings (64% [95% CI: 39%-84%] for both) (P < .05 for both comparisons). Most medical centers reported morphine as first-line therapy (82%; 95% CI: 69%-90%) and level 3 and level 4 NICUs as the location of pharmacologic treatment (83%; 95% CI: 71%-91%). CONCLUSIONS Observed variations in care between NICUs and non-ICUs revealed opportunities for targeted interventions in training and standardized care plans in non-ICU sites.
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Affiliation(s)
- Jessica N Snowden
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas;
| | - A Akshatha
- Kapiolani Women and Children's Hospital, Honolulu, Hawaii
| | - Robert D Annett
- University of Mississippi Medical Center, Jackson, Mississippi
| | | | - Abhik Das
- RTI International, Research Triangle Park, North Carolina
| | - Lori A Devlin
- Department of Pediatrics, University of Louisville, Louisville, Kentucky
| | - Rosemary D Higgins
- College of Health and Human Services, George Mason University, Fairfax, Virginia
| | - Zhuopei Hu
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Elizabeth Lindsay
- Department of Pediatrics, Section of Neonatology, Tulane University, New Orleans, Louisiana
| | | | - Clare Campbell Nesmith
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | - Judith Ross
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Alan E Simon
- Environmental Influences on Child Health Outcomes Program, National Institutes of Health, Bethesda, Maryland
| | - M Cody Smith
- West Virginia University Medical Center, Morgantown, West Virginia
| | - Christine B Turley
- Department of Pediatrics, College of Medicine, University of South Carolina, Columbia, South Carolina
| | - Anita Walden
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Leslie Young
- University of Vermont Medical Center, Burlington, Vermont; and
| | - Bonny Whalen
- Children's Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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40
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Jones HE, Kraft WK. Analgesia, Opioids, and Other Drug Use During Pregnancy and Neonatal Abstinence Syndrome. Clin Perinatol 2019; 46:349-366. [PMID: 31010564 DOI: 10.1016/j.clp.2019.02.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
When opioid misuse rises in the United States, pregnant women and their neonates are affected. This article summarizes the use of Food and Drug Administration-approved products, including methadone, buprenorphine, and the combination formulation of buprenorphine and naloxone to treat adult opioid use disorder during the perinatal period. All labels include pregnancy, neonatal, and lactation information and note the accepted use of these medications during the perinatal period if the benefits outweigh the risks. A summary of the neonatal abstinence syndrome definition, its assessment tools, treatment approaches, and future genetic directions are provided.
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Affiliation(s)
- Hendrée E Jones
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, UNC Horizons, 410 North Greensboro Street, Chapel Hill, NC, USA; Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Department of Obstetrics and Gynecology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
| | - Walter K Kraft
- Clinical Research Unit, Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, 1170 Main Building, 132 South 10th Street, Philadelphia, PA 19107-5244, USA
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41
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Haas A. Identification of neonatal abstinence syndrome in the community: Infants born into Canada's opioid crisis. Paediatr Child Health 2019; 24:81-84. [PMID: 30996597 DOI: 10.1093/pch/pxy098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Opioid use in Canada continues to rise. Infants exposed to opioids in utero are at high risk for neonatal abstinence syndrome. Signs and symptoms of withdrawal may not develop before the infant is discharged home. Health professionals may be falling short in adequately identifying and supporting opioid-exposed infants and their families. In the absence of universal toxicology screening, nurses in the community play an instrumental role in assessing, referring, and supporting these families.
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Affiliation(s)
- Amanda Haas
- University of Saskatchewan - College of Nursing, Saskatoon, Saskatchewan, Saskatchewan.,University of Saskatchewan, Saskatoon, Saskatchewan
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42
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Whalen BL, Holmes AV, Blythe S. Models of care for neonatal abstinence syndrome: What works? Semin Fetal Neonatal Med 2019; 24:121-132. [PMID: 30926259 DOI: 10.1016/j.siny.2019.01.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Opioid use disorders and the prescription of long-acting medications for their treatment have increased dramatically over the last decade among pregnant women. Newborns who experience prolonged in utero opioid exposure may develop neonatal abstinence syndrome (NAS). Until recently, much of the focus on improving care for NAS has been on pharmacologically-based care models. Recent studies have illustrated the benefits of rooming-in and parental presence on NAS outcomes. Single center Quality Improvement (QI) initiatives demonstrate the benefits of non-pharmacologic care bundles and symptom prioritization in decreasing the proportion of infants pharmacologically treated and length of hospital stay. Little remains known about the impact of these varied cared models on maternal-infant attachment and mental health. In this review article, we will propose an optimal model of care to improve short- and long-term outcomes for newborns, their mothers and families, and perinatal care systems.
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Affiliation(s)
- Bonny L Whalen
- Geisel School of Medicine at Dartmouth, Children's Hospital at Dartmouth-Hitchcock, Dartmouth-Hitchcock Medical Center, DHMC Pediatrics, One Medical Center Dr., Lebanon, NH, 03756, USA.
| | - Alison V Holmes
- Geisel School of Medicine at Dartmouth, Children's Hospital at Dartmouth-Hitchcock, Dartmouth-Hitchcock Medical Center, The Dartmouth Institute, DHMC Pediatrics, One Medical Center Dr, Lebanon, NH, 03756, USA.
| | - Stacy Blythe
- School of Nursing and Midwifery, Western Sydney University, Translational Health Research Institute (THRI), Locked Bag 1797, Western Sydney University, Penrith, NSW, 2751, Australia.
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43
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Abstract
Neonates exposed prenatally to opioids will often develop a collection of withdrawal signs known as neonatal abstinence syndrome (NAS). The incidence of NAS has substantially increased in recent years placing an increasing burden on the healthcare system. Traditional approaches to assessment and management have relied on symptom-based scoring tools and utilization of slowly decreasing doses of medication, though newer models of care focused on non-pharmacologic interventions and rooming-in have demonstrated promise in reducing length of hospital stay and medication usage. Data on long-term outcomes for both traditional and newer approaches to care of infants with NAS is limited and an important area of future research. This review will examine the history, incidence and pathophysiology of NAS. We will also review diagnostic screening approaches, scoring tools, differing management approaches and conclude with recommendations for continued work to improve the care of infants with NAS.
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Affiliation(s)
- Matthew Grossman
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, United States.
| | - Adam Berkwitt
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, United States
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44
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Shining a Light: Integrating Protocols Into Clinical Practice for Treatment of Neonatal Abstinence Syndrome. J Addict Nurs 2019; 30:61-66. [PMID: 30830002 DOI: 10.1097/jan.0000000000000267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE The epidemic use of opioids is negatively influencing the health of the American people. Pregnant women and their unborn babies have not escaped the ravages of substance use. A dramatic increase in maternal opioid use has led to an increasing number of infants experiencing withdrawal symptoms known as neonatal abstinence syndrome (NAS). The purpose of this article is to highlight best practice for the management of infants with opioid withdrawal. REVIEW OF PROTOCOLS AND TREATMENTS Review of available protocols and treatments revealed wide variation in the treatment of NAS and little use of standardized guidelines or protocols, despite current recommendations of the American Academy of Pediatrics. There is supporting evidence showing that the use of standardized protocols reduces the length of treatment and enhances outcomes in the neonatal population. EVIDENCE-BASED RECOMMENDATIONS Evidence-based strategies to address gaps in practice include developing strong protocols to identify infants at risk and implementing standardized plans when treating NAS. Consistent assessment, initial treatment with nonpharmacologic measures, and conservative use of pharmacologic agents are important elements to an NAS treatment protocol. CONCLUSIONS AND IMPLICATIONS In evaluating the current literature for best practice in the management of the newborn with opioid withdrawal, it is clear that evidence-based standardized protocols need to be in place for the best treatment of the mother-infant dyad, caring for both the infants with NAS as well as the mothers with opioid use disorder.
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45
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Hall ES, McAllister JM, Wexelblatt SL. Developmental Disorders and Medical Complications Among Infants with Subclinical Intrauterine Opioid Exposures. Popul Health Manag 2019; 22:19-24. [PMID: 29893624 PMCID: PMC6386081 DOI: 10.1089/pop.2018.0016] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
The objective was to compare diagnosis rates representing developmental outcomes and medical complications between infants with intrauterine opioid exposures who did not receive pharmacologic treatment for neonatal abstinence syndrome at the time of birth and infants for whom no exposure to substances of abuse were detected. This retrospective, descriptive study included approximately 95% of Hamilton County, Ohio resident births in 2014 and 2015. Universal maternal drug test results, performed at the time of birth, were documented and linked to electronic health records representing pediatric primary and subspecialty follow-up care as well as urgent care, emergency care, and inpatient services provided by Cincinnati Children's Hospital Medical Center through 2017, when all children were at least 24 months old. Diagnosis rates were compared between drug exposure groups using chi-square tests. Among infants born at >34 weeks gestation and without other complex clinical conditions, infants with subclinical opioid exposures (N = 473) were more likely than infants with no drug exposures (N = 14,933) to be diagnosed with behavioral or emotional disorders (3.0% vs 1.1%, P = 0.0008), developmental delay (15.6% vs 7.6%, P < 0.0001), speech disorder (10.1% vs 6.5%, P = 0.001), or strabismus (3.4% vs 1.0%, P < 0.0001), and more likely to be exposed to the hepatitis C virus (6.8% vs 0.1%, P < 0.0001). Increased diagnosis rates among all opioid exposed infants, regardless of withdrawal severity, may warrant the additional allocation of resources for screening and follow-up. Awareness of the increased risk for certain developmental delays and medical conditions is critical to early intervention and treatment supporting improved outcomes.
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Affiliation(s)
- Eric S. Hall
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jennifer M. McAllister
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Scott L. Wexelblatt
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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46
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Tolia VN, Murthy K, Bennett MM, Greenberg RG, Benjamin DK, Smith PB, Clark RH. Morphine vs Methadone Treatment for Infants with Neonatal Abstinence Syndrome. J Pediatr 2018; 203:185-189. [PMID: 30220442 DOI: 10.1016/j.jpeds.2018.07.061] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 06/13/2018] [Accepted: 07/12/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To estimate the relationship of initial pharmacotherapy with methadone or morphine and length of stay (LOS) in infants with neonatal abstinence syndrome (NAS) admitted to the neonatal intensive care unit (NICU). STUDY DESIGN From the Pediatrix Clinical Data Warehouse database, we identified all infants born at ≥36 weeks of gestation between 2011 and 2015 who were diagnosed with NAS (International Classification of Diseases, Ninth Revision code 779.5) and treated with methadone or morphine in the first 7 days of life. We used multivariable Cox proportional hazards regression analysis to quantify the association between initial treatment and LOS after adjusting for maternal age, maternal race/ethnicity, maternal drug use, maternal smoking, gestational age, small for gestational age status, inborn status, and discharge year. RESULTS We identified a total of 7667 eligible infants, including 1187 treated with methadone (15%) and 6480 treated with morphine (85%). Birth weight, gestational age, and sex were similar in the 2 groups. Methadone treatment was associated with a 22% shorter median LOS (18 days [IQR, 11-30 days] vs 23 days [IQR, 16-33]; P < .001) and a 19% shorter median NICU stay (17 days [IQR, 10-29 days] vs 21 days [IQR, 14-36 days]; P < .001). After adjustment, methadone was associated with a shorter LOS (hazard ratio for discharge, 1.24; 95% CI, 1.11-1.37; P < .001) CONCLUSION: Among infants born at ≥36 weeks of gestation with NAS, initial methadone treatment was associated with a shorter LOS compared with morphine treatment. Future prospective comparative effectiveness trials to treat infants with NAS are needed to verify this observation.
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Affiliation(s)
- Veeral N Tolia
- Department of Neonatology, Baylor University Medical Center, Dallas, TX; Pediatrix Medical Group, Baylor Scott & White Health, Dallas, TX.
| | - Karna Murthy
- Division of Neonatology, Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Evanston, IL; Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Monica M Bennett
- Center for Clinical Effectiveness, Baylor Scott & White Health, Dallas, TX
| | - Rachel G Greenberg
- Division of Neonatology, Department of Pediatrics, Duke University, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | | | - P Brian Smith
- Division of Neonatology, Department of Pediatrics, Duke University, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Reese H Clark
- Pediatrix Medical Group, Greenville Memorial Hospital, Greenville, SC; Center for Research, Education, and Quality, Mednax, Inc, Sunrise, FL
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47
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Friedman H, Parkinson G, Tighiouart H, Parkinson C, Tybor D, Terrin N, Lester B, Harvey-Wilkes K, Davis JM. Pharmacologic treatment of infants with neonatal abstinence syndrome in community hospitals compared to academic medical centers. J Perinatol 2018; 38:1651-1656. [PMID: 30237476 DOI: 10.1038/s41372-018-0230-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 08/19/2018] [Accepted: 08/23/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare length of hospital stay (LOS), LOS due to neonatal abstinence syndrome (NAS), and duration of pharmacologic treatment in community or academic settings. STUDY DESIGN One hundred-two infants exposed to opioids in utero at two community hospitals were compared to 256 from eight academic centers. All infants were managed with non-pharmacologic care followed by similar pharmacologic treatment options. RESULTS Two hundred-twelve infants received pharmacologic treatment for NAS. Mean LOS (24.7 ± 8.5 vs. 24.5 ± 11.3 days), LOS due to NAS (24.0 ± 8.2 vs. 23.3 ± 9.2 days), and duration of NAS treatment (19.3 ± 8.0 vs. 18.9 ± 9.2 days) were similar in community compared to academic medical centers. CONCLUSIONS No significant differences were found in infants managed in the community compared to academic care settings. These findings support caring for opioid-exposed infants in both community and academic settings with the use of standardized care protocols.
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Affiliation(s)
- Hayley Friedman
- Division of Newborn Medicine, Tufts Medical Center, Boston, MA, USA
| | | | - Hocine Tighiouart
- The Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA.,The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | | | - David Tybor
- School of Public Health, Tufts University School of Medicine, Boston, MA, USA
| | - Norma Terrin
- The Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA
| | - Barry Lester
- Department of Pediatrics, Women and Infant's Hospital, Providence, RI, USA
| | | | - Jonathan M Davis
- Division of Newborn Medicine, Tufts Medical Center, Boston, MA, USA. .,The Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA.
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48
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Abstract
Neonatal abstinence syndrome refers to the signs and symptoms attributed to the cessation of prenatal exposure (via placental transfer) to various substances. This Primer focuses on neonatal abstinence syndrome caused by opioid use during pregnancy - neonatal opioid withdrawal syndrome (NOWS). As the global prevalence of opioid use has alarmingly increased, so has the incidence of NOWS. NOWS can manifest with varying severity or not at all, for unknown reasons, but is likely to be associated with multiple factors, both maternal (for example, smoking and additional substance exposures) and neonatal (gestational age, sex and genetics). Care for the infant with NOWS begins with addressing the issues experienced by pregnant women with opioid use disorder. Co-occurring mental illness, economic hardship, intimate partner violence, infectious diseases and limited access to care are common in these women and can result in poor maternal and neonatal outcomes. Although there is no consensus regarding optimal NOWS management, non-pharmacological interventions (such as breastfeeding and rooming-in of the mother and the baby) have become a priority, as they can ameliorate symptoms without the need for further opioid exposure. Untreated NOWS can be associated with morbidity in early infancy, and the long-term consequences of fetal opioid exposure are only beginning to be understood.
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Affiliation(s)
- Mara G Coyle
- Department of Pediatrics, The Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | - Susan B Brogly
- Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | - Mahmoud S Ahmed
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX, USA
| | - Stephen W Patrick
- Vanderbilt Center for Child Health Policy, Department of Pediatrics and Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hendrée E Jones
- Department of Obstetrics and Gynecology, University of North Carolina, Carrboro, NC, USA
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49
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Slowiczek L, Hein DJ, Risoldi Cochrane Z, Gregory PJ. Morphine and Methadone for Neonatal Abstinence Syndrome: A Systematic Review. Neonatal Netw 2018; 37:365-371. [PMID: 30567886 DOI: 10.1891/0730-0832.37.6.365] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
PURPOSE To compare the effects of morphine and methadone on length of hospital stay (LOS) or treatment (LOT) and adverse effects in infants with neonatal abstinence syndrome (NAS). DESIGN Systematic review. SAMPLE PubMed, Google Scholar, Cochrane library, CINAHL, IPA, American Academy of Pediatrics, and clinicaltrials.gov were systematically searched to identify randomized controlled trials (RCTs) and observational studies. comparing morphine and methadone for NAS. OUTCOMES LOS, LOT, adverse effects. RESULTS One RCT, two cohort studies, and two chart reviews met inclusion criteria. Each had a low risk of bias. LOS ranged from 12.08 to 36 days with morphine and 21 to 44.23 days with methadone. LOT ranged from 7.46 to 22.9 days (morphine) and 13.9 to 38.08 days (methadone). Adverse effects were not reported. Clinical evidence comparing morphine to methadone for NAS treatment is limited and conflicting. A recommendation for one over the other cannot be made based on these outcomes.
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50
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Ernst KD, Makkar A. THE OPIOID-EXPOSED NEONATE: A REVIEW OF THE OKLAHOMA EXPERIENCE. THE JOURNAL OF THE OKLAHOMA STATE MEDICAL ASSOCIATION 2018; 111:768-774. [PMID: 31354174 PMCID: PMC6660011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Neonatal abstinence syndrome from opioids (NAS-O) is a multisystem disorder resulting in neurological and gastrointestinal symptoms from the abrupt discontinuation of chronic fetal exposure to opioids. Increasing opioid use during pregnancy has led to a five-fold increase in NAS-O nationally over the past decade. Several knowledge gaps in our experiences with opioid-exposed neonates have been identified: 1) universal maternal screening; 2) diagnostic tools for newborn abstinence syndrome; 3) optimal treatment protocols; and 4) long-term neurodevelopmental effects of fetal opioid exposure. This review article gives a broad overview of the issues associated with screening, diagnosis, and management of opioid exposure in newborns as well as the issues with collecting accurate outcomes data to monitor efforts aimed at curbing opioid exposure in children and NAS-O. Data specific to Oklahoma is provided, when available.
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Affiliation(s)
- Kimberly D. Ernst
- Dr. Ernst is Professor, Neonatal-Perinatal Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; Medical Director of the Level II Neonatal Intensive Care Unit at SSM Health Saint Anthony, Oklahoma City, Oklahoma
| | - Abhishek Makkar
- Dr. Makkar is Assistant Professor, Neonatal-Perinatal Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; Medical Director of the Level II Neonatal Intensive Care Unit at Comanche County Hospital, Lawton, Oklahoma
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