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Uebel H, Dronavalli M, Lawler K, Lee E, Bajuk B, Burns L, Page A, Dickson M, Green C, Dicair L, Eastwood J, Oei JL. School performance in children with prenatal drug exposure and out-of-home care in NSW, Australia: a retrospective population-based cohort study. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:500-509. [PMID: 38897715 DOI: 10.1016/s2352-4642(24)00076-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 03/05/2024] [Accepted: 03/18/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Prenatal drug exposure (PDE) is a global public health problem that is strongly associated with the need for child protection services, including placement into out-of-home care (OOHC). We aimed to assess school outcomes for children with PDE (both with and without neonatal abstinence syndrome [NAS]) and the association of school performance with OOHC. METHODS Using linked population health, OOHC, and school test data, we compared results on the Australian standardised curriculum-based test, the National Assessment Program-Literacy and Numeracy (NAPLAN), for children with PDE who were born in New South Wales (NSW) between 2001 and 2020 and had completed at least one NAPLAN test between Jan 1, 2008, and June 30, 2021, administered in Year 3 (age 8-9 years), Year 5 (age 10-11 years), Year 7 (age 12-13 years), or Year 9 (age 14-15 years). Linked datasets included NSW Perinatal Data Collection (birth data), NSW Admitted Patient Data Collection (hospital diagnoses), NSW Education Standards Authority (NAPLAN scores), NSW Family and Community Services Dataset-KiDS Data Collection (OOHC information), NSW Mental Health Ambulatory Data Collection, and NSW Registry for Births, Deaths, and Marriages. The primary outcome was scoring above or below the National Minimum Standard (NMS) in any test domain (mathematics, language, writing, and spelling) at each year level, comparing the relative risk of scoring below NMS between children with and without PDE (and with or without NAS within the PDE group), and with and without OOHC contact. The association between OOHC on the likelihood of scoring above NMS was also investigated for PDE and non-PDE cohorts. FINDINGS The PDE cohort included 3836 children, and the non-PDE cohort included 897 487 children. Within the PDE cohort, 3192 children had a NAS diagnosis and 644 children had no NAS diagnosis. 1755 (45·8%) children with PDE required OOHC compared with 12 880 (1·4%) of 897 487 children without PDE. Children with PDE were more likely than children without PDE to score below NMS in any domain from Year 3 (risk ratio 2·72 [95% CI 2·58-2·76]) to Year 9 (2·36 [2·22-2·50]). Performance was similar regardless of a NAS diagnosis (Year 3: 0·96 [0·84-1·10]; Year 9: 0·98 [0·84-1·15]). The likelihood of scoring above NMS in Year 9 was reduced for children with PDE and without NAS (0·57 [0·45-0·73]) and NAS (0·58 [0·52-0·64]) compared with those without PDE, and also for children who received OOHC (0·60 [0·57-0·64]) compared with those without OOHC, when adjusted for confounders. Among children with PDE, those receiving OOHC had a similar likelihood of scoring above NMS compared with children who did not receive OOHC, from Year 3 (1·01 [0·92-1·11]) to Year 9 (0·90 [0·73-1·10]), when adjusted for confounding factors. By contrast, among children without PDE, those receiving OOHC were less likely to score above NMS than those who did not receive OOHC, from Year 3 (0·78 [0·76-0·80]) to Year 9 (0·58 [0·54-0·61]). INTERPRETATION Compared with children without PDE, school performance in children with PDE-regardless of whether they were diagnosed with NAS-is poor, and the gap widens with age. The risk of poor performance persists regardless of OOHC status. This finding underscores the need for all children with PDE to receive long-term, culturally sensitive, and proactive support to improve life success. FUNDING SPHERE Mindgardens Neuroscience Network, Australian Red Cross, Alpha Maxx Healthcare, Centre for Research Excellence for Integrated Health and Social Care, National Health and Medical Research Council, and University of Sydney.
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Affiliation(s)
- Hannah Uebel
- School of Women's and Children's Health, University of New South Wales, Kensington, NSW, Australia; Department of Paediatrics, Sydney Children's Hospital, Sydney, NSW, Australia.
| | - Mithilesh Dronavalli
- Translational Health Research Institute, Western Sydney University, Penrith, NSW, Australia
| | - Kate Lawler
- School of Women's and Children's Health, University of New South Wales, Kensington, NSW, Australia
| | - Evelyn Lee
- Centre for Social Research in Health, University of New South Wales, Kensington, NSW, Australia; Centre for Economic Impacts of Genomic Medicine, Macquarie University, North Ryde, NSW, Australia
| | - Barbara Bajuk
- Critical Care Program, Sydney Children's Hospitals Network, Sydney, NSW, Australia
| | - Lucinda Burns
- National Drug and Alcohol Research Centre, University of New South Wales, Kensington, NSW, Australia
| | - Andrew Page
- Translational Health Research Institute, Western Sydney University, Penrith, NSW, Australia
| | - Michelle Dickson
- The Poche Centre for Indigenous Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
| | | | - Lauren Dicair
- The Poche Centre for Indigenous Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
| | - John Eastwood
- National Public Health Service, Te Whatu Ora-Health New Zealand, Dunedin, New Zealand; School of Population Health, University of New South Wales, Kensington, NSW, Australia; Department of Preventative and Social Medicine, University of Otago, Dunedin, New Zealand; Sydney Institute for Women Children and their Families, Sydney Local Health District, Sydney, New South Wales, Australia; Menzies Centre for Health Policy and Economics, School of Public Health, University of Sydney, Camperdown, New South Wales, Australia; Early Years Research Group, Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
| | - Ju Lee Oei
- School of Women's and Children's Health, University of New South Wales, Kensington, NSW, Australia; Department of Newborn Care, Royal Hospital for Women, Randwick, New South Wales, Australia; Drug and Alcohol Services, Murrumbidgee Local Health District, Wagga Wagga, New South Wales, Australia
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Sankaran D, Rawat S, Kachelmeyer JL, Li ES, Reynolds AM, Rawat M, Chandrasekharan P. Severe Neonatal Opioid Withdrawal Requiring Pharmacotherapy: Impact of Region of Residence. Am J Perinatol 2024; 41:e654-e663. [PMID: 35973797 DOI: 10.1055/a-1925-1659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Our objective was to evaluate the trend and to assess the impact of maternal region of residence in Western New York (WNY), on severe neonatal opioid withdrawal syndrome (NOWS). STUDY DESIGN Term infants' born at gestational age greater than or equal to 37 weeks with severe NOWS, defined as withdrawal resulting in the receipt of pharmacologic therapy from WNY admitted to our neonatal intensive care unit (NICU) from January 1, 2008 to December 31, 2016, were included. Severe NOWS admissions to our NICU from the following five regions were controlled with birth and insurance data: (1) Urban North, (2) Erie Coastal, (3) Niagara Frontier, (4) Southern Tier, and (5) Urban South. RESULTS "Urban South" residence was associated with an increased risk of severe NOWS (adjusted odds ratio = 1.8, 97.5% confidence interval: 1.1-2.9). The trend in admission for severe NOWS doubled between 2008 to 2010 and 2014 to 2016 (p = 0.01). More infants born to maternal nonprescribed opioid users were placed in foster care at discharge (36.5 vs. 1.9%, p < 0.001). CONCLUSION In WNY, neonates born to mothers from the "Urban South" were twice at risk of being admitted for severe NOWS. One-third of infants with severe NOWS after nonprescribed opioid use were placed in foster care. Implementing targeted strategies at the community level may help improve outcomes in NOWS. KEY POINTS · Maternal region of residence is a risk factor for severe neonatal opioid withdrawal.. · Admissions for severe neonatal opioid withdrawal trended up from 2008 to 2010 to 2014 to 2016.. · One-third of the infants born to mothers on nonprescribed opioids were discharged to foster care..
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Affiliation(s)
- Deepika Sankaran
- Division of Neonatology, Department of Pediatrics, University at Buffalo, Buffalo, New York
- Division of Neonatology, Department of Pediatrics, University of California at Davis, Sacramento, California
| | - Shikha Rawat
- Department of Economics, Stony Brook University, Stony Brook, New York
- Research Analyst, American Express, New York, New York
| | - Jennifer L Kachelmeyer
- Division of Neonatology, Department of Pediatrics, University at Buffalo, Buffalo, New York
| | - Emily S Li
- Division of Neonatology, Department of Pediatrics, University at Buffalo, Buffalo, New York
| | - Anne M Reynolds
- Division of Neonatology, Department of Pediatrics, University at Buffalo, Buffalo, New York
| | - Munmun Rawat
- Division of Neonatology, Department of Pediatrics, University at Buffalo, Buffalo, New York
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Lust C, Vesoulis Z, Zempel J, Gu H, Lee S, Rao R, Mathur AM. An Amplitude-Integrated EEG Evaluation of Neonatal Opioid Withdrawal Syndrome. Am J Perinatol 2024; 41:e290-e297. [PMID: 35709730 PMCID: PMC10008470 DOI: 10.1055/a-1877-9291] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Infants with neonatal opioid withdrawal syndrome (NOWS) have disrupted neurobehavior that requires hospitalization and treatment. This article aimed to evaluate electroencephalography (EEG) abnormalities using amplitude-integrated EEG (aEEG) in NOWS. STUDY DESIGN Eighteen term born infants with NOWS were recruited prospectively for an observational pilot study. aEEG monitoring was started within 24 hours of recruitment and twice weekly through discharge. aEEG data were analyzed for background and seizures. Severity of withdrawal was monitored using the modified Finnegan scoring (MFS) system. RESULTS Fifteen neonates had complete datasets. Thirteen (87%) had continuous aEEG background in all recordings. None had sleep-wake cyclicity (SWC) at initial recording. Brief seizures were noted in 9 of 15 (60%) infants. Lack of SWC was associated with higher MFS scores. At discharge, 8 of 15 (53%) had absent or emerging SWC. CONCLUSION aEEG abnormalities (absent SWC) are frequent and persist despite treatment at the time of discharge in the majority of patients with NOWS. Brief electrographic seizures are common. Neonates with persistent aEEG abnormalities at discharge warrant close follow-up. KEY POINTS · EEG abnormalities are common and persist after clinical signs resolve in patients with NOWS.. · Short subclinical seizures may be seen.. · aEEG may identify neonates who need follow-up..
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Affiliation(s)
- Christopher Lust
- Department of Neonatology, Children's Minnesota NICU, St. Louis, Missouri
| | - Zachary Vesoulis
- Division of Newborn Medicine, Department of Pediatrics, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - John Zempel
- Department of Neurology, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Hongjie Gu
- Division of Biostatistics, Washington University School of Medicine, St. Louis, Missouri
| | - Stephanie Lee
- Division of Newborn Medicine, Department of Pediatrics, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Rakesh Rao
- Division of Newborn Medicine, Department of Pediatrics, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Amit M Mathur
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Saint Louis University, St. Louis, Missouri
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Lawler K, Dronavalli M, Page A, Lee E, Uebel H, Bajuk B, Burns L, Dickson M, Green C, Dicair L, Eastwood J, Oei JL. 'Joining the Dots: Linking Prenatal Drug Exposure to Childhood and Adolescence' - research protocol of a population cohort study. BMJ Paediatr Open 2024; 8:e002557. [PMID: 38604771 PMCID: PMC11015252 DOI: 10.1136/bmjpo-2024-002557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 03/28/2024] [Indexed: 04/13/2024] Open
Abstract
INTRODUCTION Prenatal drug exposure (PDE) is one of the most important causes of child harm, but comprehensive information about the long-term outcomes of the families is difficult to ascertain. The Joining the Dots cohort study uses linked population data to understand the relationship between services, therapeutic interventions and outcomes of children with PDE. METHODS AND ANALYSIS Information from routinely collected administrative databases was linked for all births registered in New South Wales (NSW), Australia between 1 July 2001 and 31 December 2020 (n=1 834 550). Outcomes for seven mutually exclusive groups of children with varying prenatal exposure to maternal substances of addiction, including smoking, alcohol, prescription/illicit drugs and neonatal abstinence syndrome will be assessed. Key exposure measures include maternal drug use type, maternal social demographics or social determinants of health, and maternal physical and mental health comorbidities. Key outcome measures will include child mortality, academic standardised testing results, rehospitalisation and maternal survival. Data analysis will be conducted using Stata V.18.0. ETHICS AND DISSEMINATION Approvals were obtained from the NSW Population and Health Services Research Ethics Committee (29 June 2020; 2019/ETH12716) and the Australian Capital Territory Health Human Research Ethics Committee (11 October 2021; 2021-1231, 2021-1232, 2021-1233); and the Aboriginal Health and Medical Research Council (5 July 2022; 1824/21), and all Australian educational sectors: Board of Studies (government schools), Australian Independent Schools and Catholic Education Commission (D2014/120797). Data were released to researchers in September 2022. Results will be presented in peer-reviewed academic journals and at international conferences. Collaborative efforts from similar datasets in other countries are welcome.
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Affiliation(s)
- Kate Lawler
- School of Women's and Children's Health, Faculty of Medicine and Health, University of New South Wales, Randwick, New South Wales, Australia
| | - Mithilesh Dronavalli
- School of Women's and Children's Health, Faculty of Medicine and Health, University of New South Wales, Randwick, New South Wales, Australia
- Translational Health Research Institute, Western Sydney University, Penrith, New South Wales, Australia
| | - Andrew Page
- Translational Health Research Institute, Western Sydney University, Penrith, New South Wales, Australia
| | - Evelyn Lee
- Centre for Social Research in Health, University of New South Wales, Randwick, New South Wales, Australia
- Centre for Economic Impacts of Genomic Medicine, Macquarie University, North Ryde, New South Wales, Australia
| | - Hannah Uebel
- School of Women's and Children's Health, Faculty of Medicine and Health, University of New South Wales, Randwick, New South Wales, Australia
- Sydney Children's Hospital Randwick, Randwick, New South Wales, Australia
| | - Barbara Bajuk
- Critical Care Program, Sydney Children's Hospitals Network Randwick and Westmead, Westmead, New South Wales, Australia
| | - Lucinda Burns
- National Drug and Alcohol Research Centre, University of New South Wales, Randwick, New South Wales, Australia
| | - Michelle Dickson
- The Poche Centre for Indigenous Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | | | | | - John Eastwood
- National Public Health Service, Te Whatu Ora-Health New Zealand, Dunedin, New Zealand
- School of Population Health, University of New South Wales, Randwick, New South Wales, Australia
| | - Ju Lee Oei
- School of Women's and Children's Health, Faculty of Medicine and Health, University of New South Wales, Randwick, New South Wales, Australia
- Department of Newborn Care, Royal Hospital for Women, Randwick, New South Wales, Australia
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Hite MK, Chroust AJ, Proctor-Williams K, Lowe JL. Newborn Hearing Screening Results for Infants With Prenatal Opioid Exposure in Southern Appalachia. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2024; 67:1268-1280. [PMID: 38517271 DOI: 10.1044/2024_jslhr-23-00492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
PURPOSE Infants prenatally exposed to opioids exhibit withdrawal symptomology that introduce physiological noise and can impact newborn hearing screening results. This study compared the referral rate and physiological noise interpreted by number of trials rejected due to artifact on initial newborn hearing screenings of infants with prenatal opioid exposure (POE) and infants with no opioid exposure (NOE). Furthermore, within the POE group, it examined the relationship of referral rates with severity of withdrawal symptomology, and with maternal and infant risk factors. METHOD This study used a retrospective cohort design of electronic medical records from six delivery hospitals in South-Central Appalachia. Newborn hearing screenings were conducted using automated auditory brainstem response (ABR) for 334 infants with POE and 226 infants with NOE. Severity of withdrawal symptomology was measured using the Modified Finnegan Neonatal Abstinence Scoring Tool, which includes observation of behaviors that introduce physiological noise. RESULTS There was no significant difference in newborn hearing screening referral rate between infants with POE and infants with NOE. Referral rate was not affected by maternal or infant risk factors. Infants with POE had statistically significant higher artifact (defined as rejected ABR sweeps) than infants with NOE. There was a strong positive correlation between Finnegan scores and artifact but not referral rates. Sensitivity and specificity analysis indicated artifact decreased substantially after Day 4 of life. CONCLUSIONS Referral rates of infants with POE were similar to those of infants with NOE. Nevertheless, the withdrawal symptomology of infants with POE introduces physiological noise reflected as artifact on ABR, which can affect efficiency of newborn hearing screenings.
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Affiliation(s)
- Marcy K Hite
- Department of Audiology and Speech Language Pathology, East Tennessee State University, Johnson City
| | - Alyson J Chroust
- Department of Psychology, East Tennessee State University, Johnson City
| | - Kerry Proctor-Williams
- Department of Audiology and Speech Language Pathology, East Tennessee State University, Johnson City
| | - Jennifer L Lowe
- Department of Audiology and Speech Language Pathology, East Tennessee State University, Johnson City
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West KD, Ali MM, Natzke B, Nguyen L. Health Services Use Among Children With Prenatal Substance Exposure or Neonatal Abstinence Syndrome. Psychiatr Serv 2024; 75:287-290. [PMID: 37711020 DOI: 10.1176/appi.ps.20220459] [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: 09/16/2023]
Abstract
OBJECTIVE Infants with prenatal substance exposure or neonatal abstinence syndrome (NAS) use health services more often than other children; however, little is known about their use of mental health services and psychotropic medication. METHODS The sample (N=1,004,085) consisted of infants born in 2016 in 38 states who were followed through the fifth year of life and enrolled each year in Medicaid or the Children's Health Insurance Program. Infants with prenatal substance exposure or NAS were identified with ICD-10 diagnosis codes; procedure and revenue codes documented their service use. RESULTS Rates of any mental health visit and of psychotropic medication use were higher among infants with prenatal substance exposure or NAS compared with infants without either condition; these patterns persisted during most years of the 5-year study. CONCLUSIONS Infants' elevated mental health services use through their first 5 years of life highlights the importance of early screening and subsequent engagement in school-based mental health interventions.
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Affiliation(s)
- Kristina D West
- Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, Washington, D.C. (West, Ali); Mathematica, Washington, D.C. (Natzke, Nguyen)
| | - Mir M Ali
- Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, Washington, D.C. (West, Ali); Mathematica, Washington, D.C. (Natzke, Nguyen)
| | - Brenda Natzke
- Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, Washington, D.C. (West, Ali); Mathematica, Washington, D.C. (Natzke, Nguyen)
| | - Linda Nguyen
- Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, Washington, D.C. (West, Ali); Mathematica, Washington, D.C. (Natzke, Nguyen)
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Yun HJ, Nagaraj UD, Grant PE, Merhar SL, Ou X, Lin W, Acheson A, Grewen K, Kline-Fath BM, Im K. A Prospective Multi-Institutional Study Comparing the Brain Development in the Third Trimester between Opioid-Exposed and Nonexposed Fetuses Using Advanced Fetal MR Imaging Techniques. AJNR Am J Neuroradiol 2024; 45:218-223. [PMID: 38216298 DOI: 10.3174/ajnr.a8101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/07/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND AND PURPOSE While the adverse neurodevelopmental effects of prenatal opioid exposure on infants and children in the United States are well described, the underlying causative mechanisms have yet to be fully understood. This study aims to compare quantitative volumetric and surface-based features of the fetal brain between opioid-exposed fetuses and unexposed controls by using advanced MR imaging processing techniques. MATERIALS AND METHODS This is a multi-institutional IRB-approved study in which pregnant women with and without opioid use during the current pregnancy were prospectively recruited to undergo fetal MR imaging. A total of 14 opioid-exposed (31.4 ± 2.3 weeks of gestation) and 15 unexposed (31.4 ± 2.4 weeks) fetuses were included. Whole brain volume, cortical plate volume, surface area, sulcal depth, mean curvature, and gyrification index were computed as quantitative features by using our fetal brain MR imaging processing pipeline. RESULTS After correcting for gestational age, fetal sex, maternal education, polysubstance use, high blood pressure, and MR imaging acquisition site, all of the global morphologic features were significantly lower in the opioid-exposed fetuses compared with the unexposed fetuses, including brain volume, cortical volume, cortical surface area, sulcal depth, cortical mean curvature, and gyrification index. In regional analysis, the opioid-exposed fetuses showed significantly decreased surface area and sulcal depth in the bilateral Sylvian fissures, central sulci, parieto-occipital fissures, temporal cortices, and frontal cortices. CONCLUSIONS In this small cohort, prenatal opioid exposure was associated with altered fetal brain development in the third trimester. This adds to the growing body of literature demonstrating that prenatal opioid exposure affects the developing brain.
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Affiliation(s)
- Hyuk Jin Yun
- From the Division of Newborn Medicine (H.J.Y, P.E.G., K.I.), Boston Children's Hospital, Boston, MA
- Harvard Medical School (H.J.Y, P.E.G., K.I.), Boston, MA
| | - Usha D Nagaraj
- Department of Radiology and Medical Imaging (U.D.N., B.M.K.-F.), Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- University of Cincinnati College of Medicine (U.D.N., S.L.M., B.M.K.-F.), Cincinnati, OH
| | - P Ellen Grant
- From the Division of Newborn Medicine (H.J.Y, P.E.G., K.I.), Boston Children's Hospital, Boston, MA
- Harvard Medical School (H.J.Y, P.E.G., K.I.), Boston, MA
- Department of Radiology (P.E.G.), Boston Children's Hospital, Boston, MA
| | - Stephanie L Merhar
- University of Cincinnati College of Medicine (U.D.N., S.L.M., B.M.K.-F.), Cincinnati, OH
- Division of Neonatology, Perinatal Institute (S.L.M.), Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Xiawei Ou
- Departments of Radiology and Pediatrics (X.O.), University of Arkansas for Medical Sciences, Little Rock, AR
| | - Weili Lin
- Department of Radiology (W.L.), University of North Carolina, Chappel Hill, NC
| | - Ashley Acheson
- Department of Psychiatry and Behavioral Sciences (A.A.), University of Arkansas for Medical Sciences, Little Rock, AR
| | - Karen Grewen
- Department of Psychiatry (K.G.), University of North Carolina, Chappel Hill, NC
| | - Beth M Kline-Fath
- Department of Radiology and Medical Imaging (U.D.N., B.M.K.-F.), Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- University of Cincinnati College of Medicine (U.D.N., S.L.M., B.M.K.-F.), Cincinnati, OH
| | - Kiho Im
- From the Division of Newborn Medicine (H.J.Y, P.E.G., K.I.), Boston Children's Hospital, Boston, MA
- Harvard Medical School (H.J.Y, P.E.G., K.I.), Boston, MA
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Radhakrishna U, Sadhasivam S, Radhakrishnan R, Forray A, Muvvala SB, Metpally RP, Patel S, Rawal RM, Vishweswaraiah S, Bahado-Singh RO, Nath SK. Placental cytochrome P450 methylomes in infants exposed to prenatal opioids: exploring the effects of neonatal opioid withdrawal syndrome on health horizons. Front Genet 2024; 14:1292148. [PMID: 38264209 PMCID: PMC10805101 DOI: 10.3389/fgene.2023.1292148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/24/2023] [Indexed: 01/25/2024] Open
Abstract
Background: Neonatal opioid withdrawal syndrome (NOWS), arises due to increased opioid use during pregnancy. Cytochrome P450 (CYP) enzymes play a pivotal role in metabolizing a wide range of substances in the human body, including opioids, other drugs, toxins, and endogenous compounds. The association between CYP gene methylation and opioid effects is unexplored and it could offer promising insights. Objective: To investigate the impact of prenatal opioid exposure on disrupted CYPs in infants and their anticipated long-term clinical implications. Study Design: DNA methylation levels of CYP genes were analyzed in a cohort of 96 placental tissues using Illumina Infinium MethylationEPIC (850 k) BeadChips. This involved three groups of placental tissues: 32 from mothers with infants exposed to opioids prenatally requiring pharmacologic treatment for NOWS, 32 from mothers with prenatally opioid-exposed infants not needing NOWS treatment, and 32 from unexposed control mothers. Results: The study identified 20 significantly differentially methylated CpG sites associated with 17 distinct CYP genes, with 14 CpGs showing reduced methylation across 14 genes (CYP19A1, CYP1A2, CYP4V2, CYP1B1, CYP24A1, CYP26B1, CYP26C1, CYP2C18, CYP2C9, CYP2U1, CYP39A1, CYP2R1, CYP4Z1, CYP2D7P1 and), while 8 exhibited hypermethylation (CYP51A1, CYP26B1, CYP2R1, CYP2U1, CYP4X1, CYP1A2, CYP2W1, and CYP4V2). Genes such as CYP1A2, CYP26B1, CYP2R1, CYP2U1, and CYP4V2 exhibited both increased and decreased methylation. These genes are crucial for metabolizing eicosanoids, fatty acids, drugs, and diverse substances. Conclusion: The study identified profound methylation changes in multiple CYP genes in the placental tissues relevant to NOWS. This suggests that disruption of DNA methylation patterns in CYP transcripts might play a role in NOWS and may serve as valuable biomarkers, suggesting a future pathway for personalized treatment. Further research is needed to confirm these findings and explore their potential for diagnosis and treatment.
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Affiliation(s)
- Uppala Radhakrishna
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
- Department of Obstetrics and Gynecology, Corewell Health William Beaumont University Hospital, Royal Oak, MI, United States
| | - Senthilkumar Sadhasivam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Rupa Radhakrishnan
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Ariadna Forray
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
| | - Srinivas B. Muvvala
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
| | - Raghu P. Metpally
- Department of Molecular and Functional Genomics, Geisinger, Danville, PA, United States
| | - Saumya Patel
- Department of Botany, Bioinformatics and Climate Change Impacts Management, School of Science, Gujarat University, Ahmedabad, India
| | - Rakesh M. Rawal
- Department of Life Sciences, School of Sciences, Gujarat University, Ahmedabad, India
| | - Sangeetha Vishweswaraiah
- Department of Obstetrics and Gynecology, Corewell Health William Beaumont University Hospital, Royal Oak, MI, United States
| | - Ray O. Bahado-Singh
- Department of Obstetrics and Gynecology, Corewell Health William Beaumont University Hospital, Royal Oak, MI, United States
| | - Swapan K. Nath
- Arthritis and Clinical Immunology Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, United States
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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: 0] [Impact Index Per Article: 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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10
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Gowen AM, Yi J, Stauch K, Miles L, Srinivasan S, Odegaard K, Pendyala G, Yelamanchili SV. In utero and post-natal opioid exposure followed by mild traumatic brain injury contributes to cortical neuroinflammation, mitochondrial dysfunction, and behavioral deficits in juvenile rats. Brain Behav Immun Health 2023; 32:100669. [PMID: 37588011 PMCID: PMC10425912 DOI: 10.1016/j.bbih.2023.100669] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 07/22/2023] [Indexed: 08/18/2023] Open
Abstract
Maternal opioid use poses a significant health concern not just to the expectant mother but also to the fetus. Notably, increasing numbers of children born suffering from neonatal opioid withdrawal syndrome (NOWS) further compounds the crisis. While epidemiological research has shown the heightened risk factors associated with NOWS, little research has investigated what molecular mechanisms underly the vulnerabilities these children carry throughout development and into later life. To understand the implications of in utero and post-natal opioid exposure on the developing brain, we sought to assess the response to one of the most common pediatric injuries: minor traumatic brain injury (mTBI). Using a rat model of in utero and post-natal oxycodone (IUO) exposure and a low force weight drop model of mTBI, we show that not only neonatal opioid exposure significantly affects neuroinflammation, brain metabolites, synaptic proteome, mitochondrial function, and altered behavior in juvenile rats, but also, in conjunction with mTBI these aberrations are further exacerbated. Specifically, we observed long term metabolic dysregulation, neuroinflammation, alterations in synaptic mitochondria, and impaired behavior were impacted severely by mTBI. Our research highlights the specific vulnerability caused by IUO exposure to a secondary stressor such as later life brain injury. In summary, we present a comprehensive study to highlight the damaging effects of prenatal opioid abuse in conjunction with mild brain injury on the developing brain.
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Affiliation(s)
- Austin M. Gowen
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Jina Yi
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Kelly Stauch
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Luke Miles
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE, USA
- Department of Psychological and Brain Sciences, Dartmouth College, Hanover, NH, USA
| | - Sanjay Srinivasan
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE, USA
- Department of Biological Sciences, University of Nebraska at Omaha, Omaha, NE, USA
| | - Katherine Odegaard
- Department of Biological Sciences, Florida State University, Tallahassee, FL, USA
| | - Gurudutt Pendyala
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE, USA
- Department of Genetics, Cell Biology and Anatomy, UNMC, Omaha, NE, 68198, USA
- Child Health Research Institute, Omaha, NE, 68198, USA
- National Strategic Research Institute, UNMC, Omaha, NE, USA
| | - Sowmya V. Yelamanchili
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE, USA
- Department of Genetics, Cell Biology and Anatomy, UNMC, Omaha, NE, 68198, USA
- National Strategic Research Institute, UNMC, Omaha, NE, USA
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11
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Peltz G, Jansson LM, Adeniyi-Jones S, Cohane C, Drover D, Shafer S, Wang M, Wu M, Govindaswami B, Jegatheesan P, Argani C, Khan S, Kraft WK. Ondansetron to reduce neonatal opioid withdrawal severity a randomized clinical trial. J Perinatol 2023; 43:271-276. [PMID: 36030327 PMCID: PMC9968817 DOI: 10.1038/s41372-022-01487-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/26/2022] [Accepted: 07/29/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To determine if treatment with a 5-HT3 antagonist (ondansetron) reduces need for opioid therapy in infants at risk for neonatal opioid withdrawal syndrome (NOWS). STUDY DESIGN A multicenter, randomized, placebo controlled, double blind clinical trial of ninety (90) infants. The intervention arms were intravenous ondansetron or placebo during labor followed by a daily dose of ondansetron or placebo in infants for five days. RESULTS Twenty-two (49%) ondansetron-treated and 26 (63%) placebo-treated infants required pharmacologic treatment (p > 0.05). The Finnegan score was lower in the ondansetron-treated group (4.6 vs. 5.6, p = 0.02). A non-significant trend was noted for the duration of hospitalization. There was no difference in need for phenobarbital or clonidine therapy, or total dose of morphine in the first 15 days of NOWS treatment. CONCLUSIONS Ondansetron treatment reduced the severity of NOWS symptoms; and there was an indication that it could reduce the length of stay. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov NCT01965704.
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Affiliation(s)
- Gary Peltz
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - Lauren M Jansson
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Susan Adeniyi-Jones
- Department of Pediatrics Nemours Neonatology at Jefferson, Thomas Jefferson University, Philadelphia, PA, USA
| | - Carol Cohane
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - David Drover
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Steven Shafer
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Meiyue Wang
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Manhong Wu
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Balaji Govindaswami
- Department of Pediatrics, Santa Clara Valley Medical Center, San Jose, CA, USA
| | - Priya Jegatheesan
- Department of Pediatrics, Santa Clara Valley Medical Center, San Jose, CA, USA
| | - Cynthia Argani
- Department of Obstetrics and Gynecology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Salwa Khan
- Division of Hospital Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Walter K Kraft
- Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, PA, USA
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12
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Benninger KL, McAllister JM, Merhar SL. Neonatal Opioid Withdrawal Syndrome: An Update on Developmental Outcomes. Clin Perinatol 2023; 50:17-29. [PMID: 36868704 DOI: 10.1016/j.clp.2022.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
Infants and children with prenatal opioid exposure generally have development within the normal range; however, they seem to be at risk for behavioral problems and for lower scores on cognitive, language, and motor assessments than children without prenatal opioid exposure. It is as of yet unclear whether prenatal opioid exposure itself causes issues with development and behavior, or whether it is simply correlated, due to other confounding factors.
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Affiliation(s)
- Kristen L Benninger
- Center for Perinatal Research, The Abigail Wexner Research Institute, Nationwide Children's Hospital, 575 Children's Crossroad, WB 5203, Columbus, OH 43215, USA.
| | - Jennifer M McAllister
- Cincinnati Children's Hospital Perinatal Institute, University of Cincinnati College of Medicine, 3333 Burnet Ave, ML 7009, Cincinnati, OH 45229, USA
| | - Stephanie L Merhar
- Cincinnati Children's Hospital Perinatal Institute, University of Cincinnati College of Medicine, 3333 Burnet Ave, ML 7009, Cincinnati, OH 45229, USA
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13
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Mills-Huffnagle S, Nyland JE. Potential problems and solutions of opioid-based treatment in neonatal opioid withdrawal syndrome (NOWS): a scoping review protocol. BMJ Open 2023; 13:e067883. [PMID: 36806065 PMCID: PMC9944314 DOI: 10.1136/bmjopen-2022-067883] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
INTRODUCTION Rates of neonatal opioid withdrawal syndrome (NOWS) have paralleled the rise of opioid use during pregnancy. While short-term phenotypic symptoms of NOWS are well defined, molecular implications and long-term effects are not well understood. Preferred and first-line of treatment for NOWS includes non-pharmacological interventions; however, more than half of the NOWS neonates will need pharmacologics, with opioids as the primary pharmacological treatment. While effective at reducing symptoms, treating NOWS with opioids is paradoxical given that molecular and long-term developmental consequences with such exposure are unknown. There is a pressing need for a synthesis of current and potential/ novel treatment options for NOWS. METHODS AND ANALYSIS Following a published framework, a scoping review will be conducted to evaluate NOWS treatment, including established treatment methods and novel methods that may warrant future research and consideration. Using broad search terms, as well as Medical Subject Headings terms, a comprehensive search of PubMed, Cochrane Library, Google Scholar, CINAHL, Web of Science and Scopus, as well as references of selected literature, will take place, followed by a screening procedure to identify included and excluded articles. Included studies must address NOWS treatment, or opioid withdrawal treatment of any age group, that may or may not have been tested in preclinical or clinical models. Results will summarise the current pharmacological and non-pharmacological treatment methods for NOWS, as well as potential novel treatments with a specific interest in non-opioid pharmacological interventions. ETHICS AND DISSEMINATION This scoping review aims to broadly search preclinical and clinical literature as it relates to treatment of NOWS, including potential novel treatments with a specific interest in non-opioid pharmacological interventions. Given that this study does not directly involve human subjects or animal subjects research, Institutional Review Board (IRB) or Institutional Animal Care and Use Committee (IACUC) approval is not required. Results of this scoping review will be disseminated at conferences and submitted for publication in a peer-reviewed journal.
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Affiliation(s)
- Sara Mills-Huffnagle
- Neural and Behavioral Sciences, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Jennifer E Nyland
- Neural and Behavioral Sciences, Penn State College of Medicine, Hershey, Pennsylvania, USA
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14
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Yen E, Gaddis N, Jantzie L, Davis JM. A review of the genomics of neonatal abstinence syndrome. Front Genet 2023; 14:1140400. [PMID: 36845389 PMCID: PMC9950123 DOI: 10.3389/fgene.2023.1140400] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 02/01/2023] [Indexed: 02/12/2023] Open
Abstract
Neonatal abstinence syndrome (NAS) is a constellation of signs of withdrawal occurring after birth following in utero exposure to licit or illicit opioids. Despite significant research and public health efforts, NAS remains challenging to diagnose, predict, and manage due to highly variable expression. Biomarker discovery in the field of NAS is crucial for stratifying risk, allocating resources, monitoring longitudinal outcomes, and identifying novel therapeutics. There is considerable interest in identifying important genetic and epigenetic markers of NAS severity and outcome that can guide medical decision making, research efforts, and public policy. A number of recent studies have suggested that genetic and epigenetic changes are associated with NAS severity, including evidence of neurodevelopmental instability. This review will provide an overview of the role of genetics and epigenetics in short and longer-term NAS outcomes. We will also describe novel research efforts using polygenic risk scores for NAS risk stratification and salivary gene expression to understand neurobehavioral modulation. Finally, emerging research focused on neuroinflammation from prenatal opioid exposure may elucidate novel mechanisms that could lead to development of future novel therapeutics.
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Affiliation(s)
- Elizabeth Yen
- Department of Pediatrics, Tufts Medical Center, Boston, MA, United States
- Mother Infant Research Institute, Tufts Medical Center, Boston, MA, United States
- Tufts University School of Medicine, Boston, MA, United States
- *Correspondence: Elizabeth Yen,
| | - Nathan Gaddis
- Research Triangle Institute International, Research Triangle Park, Durham, NC, United States
| | - Lauren Jantzie
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jonathan M. Davis
- Department of Pediatrics, Tufts Medical Center, Boston, MA, United States
- Tufts University School of Medicine, Boston, MA, United States
- Tufts Clinical and Translational Sciences Institute, Boston, MA, United States
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15
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Chin EM, Kitase Y, Madurai NK, Robinson S, Jantzie LL. In utero methadone exposure permanently alters anatomical and functional connectivity: A preclinical evaluation. Front Pediatr 2023; 11:1139378. [PMID: 36911026 PMCID: PMC9995894 DOI: 10.3389/fped.2023.1139378] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 02/03/2023] [Indexed: 02/25/2023] Open
Abstract
The opioid epidemic is an ongoing public health crisis, and children born following prenatal opioid exposure (POE) have increased risk of long-term cognitive and behavioral sequelae. Clinical studies have identified reduced gray matter volume and abnormal white matter microstructure in children with POE but impacts on whole-brain functional brain connectivity (FC) have not been reported. To define effects of POE on whole brain FC and white matter injury in adult animals, we performed quantitative whole-brain structural and functional MRI. We used an established rat model of POE in which we have previously reported impaired executive function in adult rats analogous to persistent neurocognitive symptoms described in humans with POE. Pregnant Sprague-Dawley rat dams received continuous methadone (12 mg/kg/day) vs. saline infusion for 28 days via osmotic mini-pumps, exposing rats to pre- and postnatal opioid until weaning. At young adult age (P60), POE and saline exposed offspring underwent in vivo MRI included diffusion tensor imaging and functional MRI (fMRI). Results indicate that fractional anisotropy (FA) was decreased in adult animals with POE [n = 11] compared to animals that received saline [n = 9] in major white matter tracts, including the corpus callosum (p < 0.001) and external capsule (p < 0.01). This change in FA was concomitant with reduced axial diffusivity in the external capsule (p < 0.01) and increased radial diffusivity in the corpus callosum (p < 0.01). fMRI analyses reveal brainwide FC was diffusely lower in POE (p < 10-6; 10% of variance explained by group). Decreased connectivity in cortical-cortical and cortico-basal ganglia circuitry was particularly prominent with large effect sizes (Glass's Δ > 1). Taken together, these data confirm POE reduces brainwide functional connectivity as well as microstructural integrity of major white matter tracts. Altered neural circuitry, dysregulated network refinement, and diffuse network dysfunction have been implicated in executive function deficits that are common in children with POE. FC may serve as a translatable biomarker in children with POE.
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Affiliation(s)
- Eric M. Chin
- Department of Neurodevelopmental Medicine, Phelps Center for Cerebral Palsy and Neurodevelopmental Medicine, Kennedy Krieger Institute, Baltimore, MD, United States
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Yuma Kitase
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Nethra K. Madurai
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Shenandoah Robinson
- Department of Neurodevelopmental Medicine, Phelps Center for Cerebral Palsy and Neurodevelopmental Medicine, Kennedy Krieger Institute, Baltimore, MD, United States
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Lauren L. Jantzie
- Department of Neurodevelopmental Medicine, Phelps Center for Cerebral Palsy and Neurodevelopmental Medicine, Kennedy Krieger Institute, Baltimore, MD, United States
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Correspondence: Lauren L. Jantzie
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16
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Balalian AA, Graeve R, Richter M, Fink A, Kielstein H, Martins SS, Philbin MM, Factor-Litvak P. Prenatal exposure to opioids and neurodevelopment in infancy and childhood: A systematic review. Front Pediatr 2023; 11:1071889. [PMID: 36896405 PMCID: PMC9989202 DOI: 10.3389/fped.2023.1071889] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 01/23/2023] [Indexed: 02/23/2023] Open
Abstract
Aim This systematic review aims to estimate the relationship between prenatal exposure to opioids and neurodevelopmental outcomes and examines potential sources of heterogeneity between the studies. Methods We searched four databases through May 21st, 2022: PubMed, Embase, PsycInfo and the Web of Science according to a specified search strings. Study inclusion criteria include: (1) cohort and case-control peer-reviewed studies published in English; (2) studies comparing neurodevelopmental outcomes among children with prenatal opioid-exposure (prescribed or used non-medically) vs. an unexposed group. Studies investigating fetal alcohol syndrome or a different primary prenatal exposure other than opioids were excluded. Two main performed data extraction using "Covidence" systematic review platform. This systematic review was conducted in accordance with PRISMA guidelines. The Newcastle-Ottawa-Scale was used for quality assessment of the studies. Studies were synthesized based on the type of neurodevelopmental outcome and the instrument used to assess neurodevelopment. Results Data were extracted from 79 studies. We found significant heterogeneity between studies due to their use of different instruments to explore cognitive skills, motor, and behavioral outcomes among children of different ages. The other sources of heterogeneity included: procedures to assess prenatal exposure to opioids; period of pregnancy in which exposure was assessed; type of opioids assessed (non-medical, medication used for opioid use dis-order, prescribed by health professional), types of co-exposure; source of selection of prenatally exposed study participants and comparison groups; and methods to address lack of comparability between exposed and unexposed groups. Cognitive and motor skills as well as behavior were generally negatively affected by prenatal opioid exposure, but the significant heterogeneity precluded a meta-analysis. Conclusion We explored sources of heterogeneity in the studies assessing the association between prenatal exposure to opioids and neurodevelopmental outcomes. Sources of heterogeneity included different approaches to participant recruitment as well as exposure and outcome ascertainment methods. Nonetheless, overall negative trends were observed between prenatal opioid exposure and neuro-developmental outcomes.
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Affiliation(s)
- Arin A Balalian
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States
| | - Richard Graeve
- Medical Faculty, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Matthias Richter
- Social Determinants of Health Group, Department of Sport and Health Sciences, Technical University of Munich (TUM), Germany
| | - Astrid Fink
- Department of Health and Consumer Protection, Kreis Groß-Gerau, Groß-Gerau, Germany
| | - Heike Kielstein
- Institut für Anatomie und Zellbiologie, Martin-Luther-Universität Halle, Halle (Saale), Germany
| | - Silvia S Martins
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States
| | - Morgan M Philbin
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, United States
| | - Pam Factor-Litvak
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States
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17
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Oei JL, Blythe S, Dicair L, Didden D, Preisz A, Lantos J. What's in a name? The ethical implications and opportunities in diagnosing an infant with neonatal abstinence syndrome (NAS). Addiction 2023; 118:4-6. [PMID: 36084928 DOI: 10.1111/add.16022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 07/27/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Ju Lee Oei
- Department of Newborn Care, Royal Hospital for Women, Randwick, NSW, Australia.,School of Women's and Children's Health, University of New South Wales, Randwick, NSW, Australia
| | - Stacy Blythe
- School of Nursing and Midwifery, Western Sydney University, Campbelltown, NSW, Australia
| | | | - David Didden
- Office of Maternal, Child, and Family Health, Charleston, WV, USA
| | - Anne Preisz
- Clinical Ethics, Sydney Children's Hospital Network, Westmead and Randwick, NSW, Australia.,Sydney Health Ethics, University of Sydney, Camperdown, NSW, Australia
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18
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Minakova E, Mikati MO, Madasu MK, Conway SM, Baldwin JW, Swift RG, McCullough KB, Dougherty JD, Maloney SE, Al-Hasani R. Perinatal oxycodone exposure causes long-term sex-dependent changes in weight trajectory and sensory processing in adult mice. Psychopharmacology (Berl) 2022; 239:3859-3873. [PMID: 36269379 DOI: 10.1007/s00213-022-06257-8] [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: 05/10/2022] [Accepted: 10/03/2022] [Indexed: 11/28/2022]
Abstract
RATIONALE In utero opioid exposure is associated with lower weight and a neonatal opioid withdrawal syndrome (NOWS) at birth, along with longer-term adverse neurodevelopmental outcomes and mood disorders. While NOWS is sometimes treated with continued opioids, clinical studies have not addressed if long-term neurobehavioral outcomes are worsened with continued postnatal exposure to opioids. In addition, pre-clinical studies comparing in utero only opioid exposure to continued post-natal opioid administration for withdrawal mitigation are lacking. OBJECTIVES Here, we sought to understand the impact of continued postnatal opioid exposure on long term behavioral consequences. METHODS We implemented a rodent perinatal opioid exposure model of oxycodone (Oxy) exposure that included Oxy exposure until birth (short Oxy) and continued postnatal opioid exposure (long Oxy) spanning gestation through birth and lactation. RESULTS Short Oxy exposure was associated with a sex-specific increase in weight gain trajectory in adult male mice. Long Oxy exposure caused an increased weight gain trajectory in adult males and alterations in nociceptive processing in females. Importantly, there was no evidence of long-term social behavioral deficits, anxiety, hyperactivity, or memory deficits following short or long Oxy exposure. CONCLUSIONS Our findings suggest that offspring with prolonged opioid exposure experienced some long-term sequelae compared to pups with opioid cessation at birth. These results highlight the potential long-term consequences of opioid administration as a mitigation strategy for clinical NOWS symptomology and suggest alternatives should be explored.
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Affiliation(s)
- Elena Minakova
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Marwa O Mikati
- Department of Psychiatry, Washington University School of Medicine, Campus Box 8232, 660 South Euclid Avenue, St. Louis, MO, 63110-1093, USA.,Division of Biology and Biomedical Sciences, Washington University School of Medicine, St. Louis, MO, USA.,Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA.,Washington University Pain Management Center, Washington University School of Medicine, St. Louis, MO, USA.,Center for Clinical Pharmacology, University of Health Sciences and Pharmacy in St. Louis, St. Louis, MO, USA
| | - Manish K Madasu
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA.,Washington University Pain Management Center, Washington University School of Medicine, St. Louis, MO, USA.,Center for Clinical Pharmacology, University of Health Sciences and Pharmacy in St. Louis, St. Louis, MO, USA
| | - Sineadh M Conway
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA.,Washington University Pain Management Center, Washington University School of Medicine, St. Louis, MO, USA.,Center for Clinical Pharmacology, University of Health Sciences and Pharmacy in St. Louis, St. Louis, MO, USA
| | - Justin W Baldwin
- Division of Biology and Biomedical Sciences, Washington University School of Medicine, St. Louis, MO, USA.,Department of Biology, Washington University School of Medicine, St. Louis, MO, USA
| | - Raylynn G Swift
- Department of Psychiatry, Washington University School of Medicine, Campus Box 8232, 660 South Euclid Avenue, St. Louis, MO, 63110-1093, USA.,Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA
| | - Katherine B McCullough
- Department of Psychiatry, Washington University School of Medicine, Campus Box 8232, 660 South Euclid Avenue, St. Louis, MO, 63110-1093, USA.,Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA
| | - Joseph D Dougherty
- Department of Psychiatry, Washington University School of Medicine, Campus Box 8232, 660 South Euclid Avenue, St. Louis, MO, 63110-1093, USA.,Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA.,Intellectual and Developmental Disabilities Research Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Susan E Maloney
- Department of Psychiatry, Washington University School of Medicine, Campus Box 8232, 660 South Euclid Avenue, St. Louis, MO, 63110-1093, USA. .,Intellectual and Developmental Disabilities Research Center, Washington University School of Medicine, St. Louis, MO, USA.
| | - Ream Al-Hasani
- Division of Biology and Biomedical Sciences, Washington University School of Medicine, St. Louis, MO, USA. .,Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA. .,Washington University Pain Management Center, Washington University School of Medicine, St. Louis, MO, USA. .,Center for Clinical Pharmacology, University of Health Sciences and Pharmacy in St. Louis, St. Louis, MO, USA.
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19
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Malthaner LQ, Jetelina KK, Loria H, McLeigh JD. Healthcare utilization among children with a history of neonatal opioid withdrawal syndrome: A matched cohort study. CHILD ABUSE & NEGLECT 2022; 134:105934. [PMID: 36302288 DOI: 10.1016/j.chiabu.2022.105934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 10/04/2022] [Accepted: 10/13/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES Compare longitudinal healthcare utilization patterns in children with and without a history of neonatal opioid withdrawal syndrome (NOWS). STUDY DESIGN A retrospective matched cohort study was conducted using billing data extracted from between 2003 and 2016 in North Texas hospitals. The sample included 595 pediatric patients diagnosed with NOWS (i.e. exposed). The unexposed were patients not diagnosed with NOWS and matched 4:1 on sex, age at first encounter, and ethnicity to the exposed who received care during the same period. Multi-level regression models (accounting for clustered data structure of multiple visits per patient) compared number of hospitalizations, number of outpatient visits, number of emergency department (ED) visits, average length of stay, and healthcare expenditures across patients with and without NOWS. RESULTS Hospitalizations were significantly lower among exposed (Incidence Rate Ratio [IRR] = 0.58, 95 % Confidence Interval [CI] = 0.44-0.77) compared to unexposed. Outpatient visits, ED visits, and average length of stay was significantly higher among exposed compared to unexposed (IRR = 1.19, 95 % CI = 1.04-1.36; IRR = 1.22, 95 % CI = 1.04-1.42; IRR = 2.21, 95 % CI = 2.03-2.42, respectively). Overall healthcare expenditure was greater among exposed, as well as for patients with neurologic, endocrine, cardiac, mental disorders, respiratory, perinatal, infectious disease, eye, ear, digestive, congenital anomaly, and skin diagnoses. CONCLUSIONS Children with a diagnosis of NOWS have significantly higher healthcare expenditures, and with the exception of hospitalizations, higher healthcare utilization beyond the newborn visit. These findings suggest the needs for interventions for children with NOWS beyond the immediate neonatal period.
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Affiliation(s)
- Lauren Q Malthaner
- Department of Epidemiology, Human Genetics, and Environmental Sciences, University of Texas Health Science Center School of Public Health, Dallas, TX, United States of America; Rees-Jones Center for Foster Care Excellence, Children's Health, Dallas, TX, United States of America.
| | - Katelyn K Jetelina
- Department of Epidemiology, Human Genetics, and Environmental Sciences, University of Texas Health Science Center School of Public Health, Dallas, TX, United States of America; Center for Pediatric Population Health, University of Texas Health Science Center School of Public Health, Dallas, TX, United States of America
| | - Hilda Loria
- Rees-Jones Center for Foster Care Excellence, Children's Health, Dallas, TX, United States of America; University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Jill D McLeigh
- Rees-Jones Center for Foster Care Excellence, Children's Health, Dallas, TX, United States of America; Center for Pediatric Population Health, University of Texas Health Science Center School of Public Health, Dallas, TX, United States of America
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20
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Benninger KL, Richard C, Conroy S, Newton J, Taylor HG, Sayed A, Pietruszewski L, Nelin MA, Batterson N, Maitre NL. One-Year Neurodevelopmental Outcomes After Neonatal Opioid Withdrawal Syndrome: A Prospective Cohort Study. PERSPECTIVES OF THE ASHA SPECIAL INTEREST GROUPS 2022; 7:1019-1032. [PMID: 36211832 PMCID: PMC9539823 DOI: 10.1044/2022_persp-21-00270] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
PURPOSE The aims of this study were, in a cohort of children with neonatal opioid withdrawal syndrome (NOWS), (a) to report 1-year neurodevelopmental outcomes and specifically characterize speech, language, and hearing outcomes and (b) to report the prevalence of cleft lip and/or cleft palate. METHOD This prospective observational cohort study includes newborns with confirmed in utero opioid exposure who received pharmacological treatment for NOWS. During 1-year-old developmental visits, we administered standardized assessments (Bayley Scales of Infant and Toddler Development-Third Edition [Bayley-III] or Developmental Assessment of Young Children-Second Edition [DAYC-2]-due to COVID-19 restrictions). We compared Bayley-III scores to standardized population means using one-sample z tests. We report estimates, 95% confidence intervals, and two-sided p values. RESULTS We enrolled 202 infants (October 2018 to March 2020). Follow-up at 1-year was 80%. Infants with NOWS had lower Bayley-III scores at 1 year compared to published norms for cognitive, language, and motor domains. One infant with NOWS was diagnosed with isolated cleft palate and Pierre Robin sequence. All infants passed the newborn hearing screen, and 7.5% had a formal hearing evaluation after neonatal intensive care unit discharge, with 40% having abnormal or inconclusive results; middle ear effusion was the leading cause of abnormal hearing (66.7%). Ten percent of children received a speech-language pathology referral prior to 2 years of age. Infants born to mothers with mental health conditions were more likely to have Bayley-III or DAYC-2 scores below 95 in language or motor domains. CONCLUSIONS Infants with pharmacologically treated NOWS have significantly lower cognitive, language, and motor scores on standardized developmental testing compared to population means at 1 year of age. Early speech-language pathology referral is frequently necessary to promote optimal development in this population. SUPPLEMENTAL MATERIAL https://doi.org/10.23641/asha.20044403.
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Affiliation(s)
- Kristen L. Benninger
- Department of Pediatrics, Nationwide Children’s Hospital and The Ohio State University Wexner Medical Center, Columbus
- Center for Perinatal Research, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH
| | - Celine Richard
- Department of Otolaryngology, The University of Tennessee Health Science Center College of Medicine, Memphis
- Department of Otolaryngology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Sara Conroy
- Biostatistics Core, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH
- Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus
| | - Julia Newton
- Center for Perinatal Research, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH
| | - H. Gerry Taylor
- Department of Pediatrics, Nationwide Children’s Hospital and The Ohio State University Wexner Medical Center, Columbus
- Center for Biobehavioral Health, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH
| | - Alaisha Sayed
- Department of Pediatrics, Nationwide Children’s Hospital and The Ohio State University Wexner Medical Center, Columbus
- Center for Perinatal Research, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH
| | - Lindsay Pietruszewski
- Center for Perinatal Research, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH
| | - Mary Ann Nelin
- Department of Pediatrics, Nationwide Children’s Hospital and The Ohio State University Wexner Medical Center, Columbus
| | - Nancy Batterson
- Department of Pediatrics, Nationwide Children’s Hospital and The Ohio State University Wexner Medical Center, Columbus
- Center for Perinatal Research, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH
| | - Nathalie L. Maitre
- Department of Pediatrics, Emory University and Children’s Healthcare of Atlanta, GA
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21
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Peacock-Chambers E, Buckley D, Lowell A, Clark MC, Friedmann PD, Byatt N, Feinberg E. Relationship-Based Home Visiting Services for Families Affected by Substance Use Disorders: A Qualitative Study. JOURNAL OF CHILD AND FAMILY STUDIES 2022; 31:2121-2133. [PMID: 36909674 PMCID: PMC9997720 DOI: 10.1007/s10826-022-02313-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 06/18/2023]
Abstract
Home visiting programs face many challenges when providing evidence-based services to families affected by substance use disorders (SUDs). We conducted interviews and focus groups with community stakeholders and parents to elucidate important considerations when intentionally attempting to meet the needs of families affected by SUDs through home visiting programs. We identified one primary theme "Who is the client?" that describes how to ensure caregivers perceive themselves as an important focus of the program. Collectively, participants revealed that understanding caregivers' emotional experiences was critical for effectively transforming their subjective experiences of the program. These emotional experiences were related to the quality of their relationships with their children, other family members, and service providers. Three sub-themes illustrate specific examples: 1) responding to the unique emotional needs of mothers in recovery, 2) considering emotional states to inform inclusion in programs, and 3) addressing complex family dynamics related to SUDs in the home. Implications of these findings are discussed.
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Affiliation(s)
- Elizabeth Peacock-Chambers
- Department of Pediatrics, UMass Chan Medical School-Baystate, Springfield, MA, USA
- Department for Healthcare Delivery and Population Science, 3601 Main Street, Third Floor, Springfield, MA 01199, USA
| | - Deirdre Buckley
- UMass Chan Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA
| | - Amanda Lowell
- Department of Psychiatry, Yale School of Medicine, 300 George Street #901, New Haven, CT 06511, USA
- Yale Child Study Center, Yale School of Medicine, 230 South Frontage Road, New Haven, CT 06519, USA
| | - Maria Carolina Clark
- Department of Pediatrics, UMass Chan Medical School-Baystate, Springfield, MA, USA
- Department for Healthcare Delivery and Population Science, 3601 Main Street, Third Floor, Springfield, MA 01199, USA
| | - Peter D. Friedmann
- Department of Medicine, UMass Chan Medical School-Baystate, 3601 Main Street, Third Floor, Springfield, MA 01199, USA
| | - Nancy Byatt
- Department of Psychiatry, UMass Chan Medical School, 222 Maple Ave – Chang Building, Shrewsbury, MA 01655, USA
| | - Emily Feinberg
- Department of Pediatrics, Boston University School of Medicine, 72 East Concord Street, Boston, MA 02118, USA
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22
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Rutherford K, Maxwell J, Fry L, Holland P, Rigon A, Lankford A. Perceived Clinical Characteristics of Children With History of Opioid Exposure: A Speech-Language Pathology Perspective. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2022; 31:1801-1816. [PMID: 35767339 DOI: 10.1044/2022_ajslp-21-00336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
PURPOSE This research was conducted to describe the clinical characteristics of children with a history of opioid exposure as perceived by the speech-language pathologists (SLPs) treating them. METHOD Three focus groups were conducted. Participants consisted of 20 SLPs working in the schools in West Virginia who had experienced working with children with a confirmed or suspected history of opioid exposure. A thematic, qualitative analysis was conducted, whereby focus group sessions were transcribed verbatim and information was coded, organized into themes, and interpreted. RESULTS Themes of perceived clinical characteristics (speech, language, executive function, and other developmental delays) are reported to address the research question. Additionally, themes derived from the data regarding perceived significant differentiators (greater severity/needs, inconsistent performance, and atypical manifestation) and perceived confounding characteristics (safety and well-being, aspects of home environment, and effects on school environment) that are often reported in children with a history or suspected history of opioid exposure are presented. CONCLUSIONS Perceived clinical characteristics of this population, both intrinsic and situational, highlight the complex profile of this population and demonstrate the importance of considering each child from a multidimensional perspective. Additional research is needed to represent the profile of these children more completely and to identify successful supports that will improve their speech and language outcomes, educational achievement, and their overall quality of life.
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Affiliation(s)
| | | | - Lisa Fry
- Marshall University, Huntington, WV
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23
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Maxwell J, Rutherford K, Holland P, Fry L, Rigon A, Lankford A. Perceptions of Speech-Language Pathologists' Service Provision in the Opioid Epidemic: A Focus Group Study. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2022; 31:1672-1686. [PMID: 35503957 DOI: 10.1044/2022_ajslp-21-00337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
PURPOSE This research intended to identify current practices being implemented with children who have a history or suspected history of opioid exposure, as well as challenges faced by speech-language pathologists in the schools. METHOD Focus group data from three groups totaling 20 speech-language pathologists (SLPs) working in schools in West Virginia, also used in a previous study, were analyzed using qualitative thematic analysis to better understand SLP service provision to children with a history or suspected history of opioid exposure. RESULTS Results revealed two primary themes, reported as (a) service delivery in action (current practice trends and challenges) and (b) affective/cognitive manifestations (uncertainty about their role and various emotions expressed) of the SLPs who participated in the focus groups. CONCLUSIONS This study revealed important clinical implications derived from the reports of participants. Particularly, the importance of communication and advocacy in the care of these children and the need to rethink what our scope of practice means when working with this vulnerable population are discussed.
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Affiliation(s)
| | | | | | - Lisa Fry
- Marshall University, Huntington, WV
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24
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Incarceration exposure and prescription opioid use during pregnancy. Drug Alcohol Depend 2022; 235:109434. [PMID: 35405460 DOI: 10.1016/j.drugalcdep.2022.109434] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/24/2022] [Accepted: 03/25/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Prior research demonstrates a high prevalence of substance use, including opioid use, among those who have had personal or vicarious contact with the correctional system. Relatedly, alongside patterns of rising opioid use in general, opioid use during pregnancy is becoming a growing public health concern. Still, risk factors for prescription opioid use during pregnancy remain understudied. This study is the first to assess the connection between a women's personal or vicarious exposure to incarceration in the 12 months prior to birth and patterns of prenatal opioid use. METHODS Data are from the Pregnancy Risk Assessment Monitoring System (PRAMS) in 2019 (N = 17,551 mothers). Logistic and multinomial logistic regression are used to assess the association between incarceration exposure and patterns of opioid use during pregnancy. RESULTS Incarceration-exposed women were more likely to use all eight types of prescription opioids assessed in this study (Hydrocodone, Codeine, Oxycodone, Tramadol, Hydromorphone/Meperidine, Oxymorphone, Morphine, and Fentanyl). After adjustment for control variables, incarceration-exposed women were significantly more likely to report any prescription opioid use during pregnancy (OR = 1.745, 95% CI = 1.194, 2.554). Furthermore, relative to no opioid use, incarceration exposure was also associated with illicit prescription opioid use (RRR = 2.979, 1.533, 5.791). CONCLUSIONS Incarceration exposure in the year prior to birth is associated with higher odds of prescription opioid use. These findings add to the burgeoning literature that details a women's exposure to incarceration is a risk marker for substance use and engagement in health risk behaviors that can jeopardize maternal and infant wellbeing.
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25
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Long-term effects of medication for opioid use disorder in children. JAAPA 2022; 35:1-4. [DOI: 10.1097/01.jaa.0000823148.49509.67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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26
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Kinsella M, Halliday LOE, Shaw M, Capel Y, Nelson SM, Kearns RJ. Buprenorphine Compared with Methadone in Pregnancy: A Systematic Review and Meta-Analysis. Subst Use Misuse 2022; 57:1400-1416. [PMID: 35758300 DOI: 10.1080/10826084.2022.2083174] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Illicit opioid use in pregnancy is associated with adverse maternal, neonatal, and childhood outcomes. Opioid substitution is recommended, but whether methadone or buprenorphine is the optimal agent remains unclear. METHODS We searched EMBASE, PubMed, Web of Science, Scopus, Open Gray, CINAHL and the Cochrane Central Registry of Controlled Trials (CENTRAL) from inception to April 2020 for randomized controlled trials (RCTs) and cohort studies comparing methadone and buprenorphine treatment for opioid-using mothers. Included studies assessed maternal and or neonatal outcomes. We used random-effects meta-analyses to estimate summary measures for outcomes and report these separately for RCTs and cohort studies. RESULTS Of 408 abstracts screened, 20 papers were included (4 RCTs, 16 cohort, 223 and 7028 participants respectively). All RCTs (4/4) had a high risk of bias and median (IQR) Newcastle Ottawa Scale for cohort studies was 7.5 (6-9). In both RCTs and cohort studies, buprenorphine was associated with; greater offspring birth weight (weighted mean difference [WMD] 343 g (95% CI: 40-645 g) in RCT and 184 g (95% CI: 121-247 g) in cohort studies); body length at birth (WMD 2.28 cm (95% CI: 1.06-3.49 cm) in RCTs and 0.65 cm (95% CI: 0.31-0.98 cm) in cohort studies); and reduced risk of prematurity (risk ratio [RR] 0.41 (95% CI: 0.18-0.93) in RCTs and 0.63 [95% CI: 0.53-0.75] in cohort studies) when compared to methadone. All other clinical outcomes were comparable. CONCLUSIONS Compared to methadone, buprenorphine was consistently associated with improved birthweight and gestational age, however given potential biases, results should be interpreted with caution.
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Affiliation(s)
- Michael Kinsella
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Lucy O E Halliday
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | | | | | - Scott M Nelson
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Rachel J Kearns
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
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27
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Yen E, Davis JM. The immediate and long-term effects of prenatal opioid exposure. Front Pediatr 2022; 10:1039055. [PMID: 36419918 PMCID: PMC9676971 DOI: 10.3389/fped.2022.1039055] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 10/18/2022] [Indexed: 11/09/2022] Open
Abstract
The opioid epidemic has adversely affected neonates and children, yet the mechanisms by which it impacts this population are not well understood. Not only does prenatal opioid exposure result in short-term consequences shortly after birth, it also creates long-term sequelae that may predispose these children to physical, emotional, psychiatric, cognitive, and socioeconomic problems in the future. This article provides a scoping overview of the long-term effects of antenatal opioid exposure on neonates and children as well as quality improvement and research efforts to understand and mitigate this major public health concern.
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Affiliation(s)
- Elizabeth Yen
- Department of Pediatrics, Tufts Medical Center, Boston, MA, United States.,Mother Infant Research Institute, Tufts Medical Center, Boston, MA, United States
| | - Jonathan M Davis
- Department of Pediatrics, Tufts Medical Center, Boston, MA, United States.,Tufts Clinical and Translational Science Institute, Boston, MA, United States
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28
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Boardman JP, Mactier H, Devlin LA. Opioids and the developing brain: time to rethink perinatal care for infants of opioid-dependent mothers. Arch Dis Child Fetal Neonatal Ed 2022; 107:98-104. [PMID: 33597225 DOI: 10.1136/archdischild-2020-320102] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/26/2020] [Accepted: 01/14/2021] [Indexed: 11/04/2022]
Abstract
Illicit use of opioids is a global health crisis with major implications for women and children. Strategies for managing opioid use disorder (OUD) in pregnancy have been tested over the past 40 years, but studies have focused on maternal and pregnancy outcomes, with less attention given to long-term follow-up of exposed children. Here, we provide a narrative review of recent advances in the assessment and management of neonatal opioid withdrawal syndrome (NOWS), and we summarise evidence from multiple domains-neuroimaging, electrophysiology, visual development and function, neurodevelopment, behaviour, cognition and education-which suggests that prenatal opioid exposure modifies child development. Further studies are required to determine the optimal management of pregnant women with OUD and babies with NOWS. We identify knowledge gaps and suggest that future study designs should evaluate childhood outcomes, including infant brain development and long-term neurocognitive and visual function.
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Affiliation(s)
- James P Boardman
- MRC Centre for Reproductive Health, The University of Edinburgh, Edinburgh, UK .,Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Helen Mactier
- Neonatology, Princess Royal Maternity, Glasgow, UK.,Princess Royal Maternity, University of Glasgow, Glasgow, UK
| | - Lori A Devlin
- Department of Pediatrics, University of Louisville, Louisville, Kentucky, USA
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29
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Sarfi M, Eikemo M, Welle-Strand GK, Muller AE, Lehmann S. Mental health and use of health care services in opioid-exposed school-aged children compared to foster children. Eur Child Adolesc Psychiatry 2022; 31:495-509. [PMID: 33590310 PMCID: PMC8940845 DOI: 10.1007/s00787-021-01728-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 01/18/2021] [Indexed: 11/29/2022]
Abstract
Given the concerns raised regarding the effects of prenatal exposure to methadone and buprenorphine on the developmental outcomes of the children, this study assessed mental health and use of services in a national sample of school-aged children (N = 78) born to women enrolled in opioid maintenance treatment during pregnancy, compared with a group of foster children (N = 140). The majority of the opioid-exposed children lived with their birth parent(s) at the time of assessment (N = 62), while 16 lived in foster homes. Caregivers completed the Strengths and Difficulties Questionnaire (SDQ) and the Reactive Attachment Disorder scale. Teachers completed the SDQ. Three kinds of services were included in measuring service use: school-based education services, child mental health services, and hospital-based habilitation services. The main finding of the study is that children prenatally exposed to methadone or buprenorphine living with their family of origin had significantly better mental health status than their foster-placed counterparts and that of the comparison group of foster children. In addition, the exposed children living at home had less child welfare involvement, and only half of them were using any of the three services measured. The odds for using services increased significantly in accordance with increasing mental health problems, independent of group affiliation, indicating a need-based access to services. In line with other studies, we found that the odds for using one or more services was 2.3 times greater for boys than for girls. Our results contribute to a more-nuanced understanding of the developmental outcomes of prenatal exposure to methadone and buprenorphine, and factors associated with increased service use in groups of at-risk children.
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Affiliation(s)
- Monica Sarfi
- SERAF-Norwegian Centre for Addiction Research, University of Oslo, Blindern, Box 1039, 0315, Oslo, Norway. .,Vestre Viken Hospital Trust, Drammen, Norway.
| | - Marie Eikemo
- Department of Psychology, The Faculty of Social Sciences, University of Oslo, Oslo, Norway
| | - Gabrielle K. Welle-Strand
- SERAF-Norwegian Centre for Addiction Research, University of Oslo, Blindern, Box 1039, 0315 Oslo, Norway
| | | | - Stine Lehmann
- Department of Health Promotion and development, The Faculty of Psychology, University of Bergen, Bergen, Norway ,Regional Centre for Child and Youth Mental Health and Child Welfare-West, NORCE Norwegian Research Centre, Bergen, Norway
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30
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Radhakrishnan R, Vishnubhotla RV, Zhao Y, Yan J, He B, Steinhardt N, Haas DM, Sokol GM, Sadhasivam S. Global Brain Functional Network Connectivity in Infants With Prenatal Opioid Exposure. Front Pediatr 2022; 10:847037. [PMID: 35359894 PMCID: PMC8964084 DOI: 10.3389/fped.2022.847037] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 02/08/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Infants with prenatal opioid and substance exposure are at higher risk of poor neurobehavioral outcomes in later childhood. Early brain imaging in infancy has the potential to identify early brain developmental alterations that may help predict behavioral outcomes in these children. In this study, using resting-state functional MRI in early infancy, we aim to identify differences in global brain network connectivity in infants with prenatal opioid and substance exposure compared to healthy control infants. METHODS AND MATERIALS In this prospective study, we recruited 23 infants with prenatal opioid exposure and 29 healthy opioid naïve infants. All subjects underwent brain resting-state functional MRI before 3 months postmenstrual age. Covariate Assisted Principal (CAP) regression was performed to identify brain networks within which functional connectivity was associated with opioid exposure after adjusting for sex and gestational age. Associations of these significant networks with maternal comorbidities were also evaluated. Additionally, graph network metrics were assessed in these CAP networks. RESULTS There were four CAP network components that were significantly different between the opioid exposed and healthy control infants. Two of these four networks were associated with maternal psychological factors. Intra-network graph metrics, namely average flow coefficient, clustering coefficient and transitivity were also significantly different in opioid exposed infants compared to healthy controls. CONCLUSION Prenatal opioid exposure is associated with alterations in global brain functional networks compared to non-opioid exposed infants, with intra-network alterations in graph network modeling. These network alterations were also associated with maternal comorbidity, especially mental health. Large-scale longitudinal studies can help in understanding the clinical implications of these early brain functional network alterations in infants with prenatal opioid exposure.
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Affiliation(s)
- Rupa Radhakrishnan
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Ramana V Vishnubhotla
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Yi Zhao
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Jingwen Yan
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Bing He
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Nicole Steinhardt
- Indiana University School of Medicine, Indianapolis, IN, United States
| | - David M Haas
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Gregory M Sokol
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Senthilkumar Sadhasivam
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, United States.,Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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31
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Moreno-Ramos M, Sánchez-Barba M, Sánchez RG, Mirón-Canelo JA, González-Nuñez V. Incidence of Neonatal Abstinence Syndrome (NAS) in Castilla y Leon (Spain). CHILDREN 2021; 9:children9010025. [PMID: 35053650 PMCID: PMC8774299 DOI: 10.3390/children9010025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 12/11/2021] [Accepted: 12/27/2021] [Indexed: 12/03/2022]
Abstract
Introduction: Neonatal Abstinence Syndrome (NAS) is considered a Public Health problem that is defined as a group of symptoms that appear in the newborn due to withdrawal from intrauterine drug exposure. Objective: The aim of this study was to analyze the incidence of NAS in Castilla y León from 2000 to 2019. Methodology: Data of NAS cases in Castilla y León from 2000 to 2019 were obtained. NAS incidence per 1000 births was calculated and the correlation among data from different provinces and years was analyzed. Results: The cumulative incidence of NAS in Castilla y León per 1000 births between 2000-2019 was 0.91‰, with great interprovincial variability. The provinces of Zamora and Palencia stand out, with high incidence rates of NAS despite their low birth rates. The temporal trend points towards a decrease in incidence from 2000 to 2019. Opioids such as methadone, cannabis, benzodiazepines and poly-drug use are the most prevalent drugs causing NAS, and it has also been observed that methadone is being replaced by cannabis as the major cause of NAS cases at the University Hospital in Salamanca in recent years. Conclusions: The incidence of NAS in Castilla y León decreased in 2004 and remained constant until 2019, but it shows great interprovincial variability. It is necessary to implement a national NAS Registry to obtain comprehensive information regarding its incidence.
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Affiliation(s)
| | - Mercedes Sánchez-Barba
- Department of Statistics, Faculty of Medicine, University of Salamanca, 37008 Salamanca, Spain;
- Institute of Biomedical and Diagnostic Sciences (IBSAL), 37007 Salamanca, Spain
| | - Rubén García Sánchez
- Department of Pediatrics, University Hospital of Salamanca, 37008 Salamanca, Spain;
| | - José Antonio Mirón-Canelo
- Institute of Biomedical and Diagnostic Sciences (IBSAL), 37007 Salamanca, Spain
- Department of Biomedical and Diagnostic Sciences, Faculty of Medicine, University of Salamanca, 37008 Salamanca, Spain
- Instituto de Neurociencias de Castilla y León (INCYL), University of Salamanca, 37008 Salamanca, Spain
- Correspondence: (J.A.M.-C.); (V.G.-N.)
| | - Veronica González-Nuñez
- Institute of Biomedical and Diagnostic Sciences (IBSAL), 37007 Salamanca, Spain
- Instituto de Neurociencias de Castilla y León (INCYL), University of Salamanca, 37008 Salamanca, Spain
- Department Biochemistry and Molecular Biology, Faculty of Medicine, University of Salamanca, 37008 Salamanca, Spain
- Correspondence: (J.A.M.-C.); (V.G.-N.)
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Lum JS, Bird KM, Wilkie J, Millard SJ, Pallimulla S, Newell KA, Wright IM. Prenatal methadone exposure impairs adolescent cognition and GABAergic neurodevelopment in a novel rat model of maternal methadone treatment. Prog Neuropsychopharmacol Biol Psychiatry 2021; 110:110281. [PMID: 33571606 DOI: 10.1016/j.pnpbp.2021.110281] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 01/21/2021] [Accepted: 02/05/2021] [Indexed: 10/22/2022]
Abstract
Methadone maintenance treatment (MMT) is the most common treatment for opioid-dependent pregnant women worldwide. Despite its widespread use, MMT is associated with a variety of adverse neurodevelopmental outcomes in exposed offspring, particularly cognitive impairments. The neurobiological abnormalities underlying these cognitive impairments are, however, poorly understood. This is, in part, due to a lack of animal models that represents the standard of care that methadone is administered in the clinic, with inconsistencies in the timing, doses and durations of treatment. Here we describe the characterisation of a clinically relevant rat model of MMT in which the long-term behavioural and neurobiological effects of prenatal methadone exposure can be assessed in adolescent offspring. Female Sprague-Dawley rats were treated orally with an ascending methadone dosage schedule (5, 10, 15, 20, 25 and 30 mg/kg/day), self-administered in drinking water prior to conception, throughout gestation and lactation. Pregnancy success, maternal gestational weight gain, litter survival and size were not significantly altered in methadone-exposed animals. Methadone-exposed offspring body and brain weights were significantly lower at birth. Novel object recognition tests performed at adolescence revealed methadone-exposed offspring had impaired recognition memory. Furthermore, the rewarded T-maze alternation task demonstrated that methadone-exposed female, but not male, offspring also exhibit working memory and learning deficits. Immunoblots of the adolescent prefrontal cortex and hippocampus showed methadone-exposed offspring displayed reduced levels of mature BDNF, in addition to the GABAergic proteins, GAD67 and parvalbumin, in a sex- and brain region-specific fashion. This rat model closely emulates the clinical scenario in which methadone is administered to opioid-dependent pregnant woman and provides evidence MMT can cause cognitive impairments in adolescent offspring that may be underlined by perturbed neurodevelopment of the GABAergic system.
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Affiliation(s)
- Jeremy S Lum
- Illawarra Health and Medical Research Institute, Wollongong, NSW 2522, Australia; School of Medicine, University of Wollongong University of Wollongong, Wollongong, NSW 2522, Australia; Molecular Horizons, University of Wollongong, Wollongong, NSW 2522, Australia.
| | - Katrina M Bird
- Illawarra Health and Medical Research Institute, Wollongong, NSW 2522, Australia; School of Medicine, University of Wollongong University of Wollongong, Wollongong, NSW 2522, Australia; Molecular Horizons, University of Wollongong, Wollongong, NSW 2522, Australia
| | - Jennifer Wilkie
- Illawarra Health and Medical Research Institute, Wollongong, NSW 2522, Australia; School of Medicine, University of Wollongong University of Wollongong, Wollongong, NSW 2522, Australia
| | - Samuel J Millard
- Illawarra Health and Medical Research Institute, Wollongong, NSW 2522, Australia; School of Medicine, University of Wollongong University of Wollongong, Wollongong, NSW 2522, Australia
| | - Sachie Pallimulla
- Illawarra Health and Medical Research Institute, Wollongong, NSW 2522, Australia; School of Medicine, University of Wollongong University of Wollongong, Wollongong, NSW 2522, Australia
| | - Kelly A Newell
- Illawarra Health and Medical Research Institute, Wollongong, NSW 2522, Australia; School of Medicine, University of Wollongong University of Wollongong, Wollongong, NSW 2522, Australia; Molecular Horizons, University of Wollongong, Wollongong, NSW 2522, Australia
| | - Ian M Wright
- Illawarra Health and Medical Research Institute, Wollongong, NSW 2522, Australia; School of Medicine, University of Wollongong University of Wollongong, Wollongong, NSW 2522, Australia; University of Queensland Centre for Clinical Research, University of Queensland, Herston, QLD 4029, Australia; College of Medicine and Dentistry, James Cook University, Cairns, QLD 4870, Australia
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Letter in Reply. J Addict Med 2021; 16:372-373. [PMID: 34417412 DOI: 10.1097/adm.0000000000000903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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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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Letter-in-reply. J Addict Med 2021; 14:354-355. [PMID: 31972769 DOI: 10.1097/adm.0000000000000589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Economic Evaluation of Interventions for Treatment of Neonatal Opioid Withdrawal Syndrome: A Review. CHILDREN-BASEL 2021; 8:children8070534. [PMID: 34201863 PMCID: PMC8306925 DOI: 10.3390/children8070534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 06/18/2021] [Accepted: 06/19/2021] [Indexed: 11/17/2022]
Abstract
This study assessed the economic evidence on the pharmacological and non-pharmacological management of infants with neonatal opioid withdrawal syndrome (NOWS). Six databases were searched up to October 2020 for peer-reviewed studies. After titles and abstracts were screened, 79 studies remained for full-text review, and finally, 8 studies were eligible for inclusion in the review. The methodological quality of included studies was assessed using the Drummond checklist. The review showed significant limitations in these studies, with one study being rated as good and the remaining seven studies as of poor quality. There are methodological issues that require addressing, including a lack of detail on cost categories, a robust investigation of uncertainty, and extending the time horizon to consider longer-term outcomes beyond the initial birth hospitalization. Despite these limitations, existing evidence suggests non-pharmacological strategies such as rooming-in were associated with a shorter hospital stay and a decreased need for pharmacological treatment, thereby lowering hospitalization costs. The review highlights the paucity of high-quality studies assessing the cost-effectiveness of intervention strategies for NOWS. There is also a lack of evidence on long-term outcomes associated with NOWS and the treatment of NOWS. The inclusion of economic analyses in future studies will provide evidence to inform policymakers on resource allocation decisions for this patient population.
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Corr TE, Xing X, Liu G. Longitudinal Health Care Utilization of Medicaid-Insured Children with a History of Neonatal Abstinence Syndrome. J Pediatr 2021; 233:82-89.e1. [PMID: 33545189 DOI: 10.1016/j.jpeds.2021.01.067] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/13/2021] [Accepted: 01/27/2021] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To describe longitudinal health care utilization of Medicaid-insured children with a history of neonatal abstinence syndrome (NAS) compared with similar children without NAS. STUDY DESIGN Retrospective, longitudinal cohort study. Data were extracted from the Medicaid Analytic eXtract files for all available states and DC from 2003-2013. Subjects were followed up to 11 years. In total, 17 229 children with NAS were identified using the International Classification of Diseases, Ninth Revision code 779.5. Children without NAS, matched on demographic and health variables, served as the comparison group. Outcomes were number of claims for inpatient, outpatient, and emergency department encounters, numbers of prescription claims, and costs associated with these services. Linked claims were identified for each subject using a unique, within-state ID. RESULTS Children with NAS had increased claims for inpatient admissions (marginal effect [ME] 0.49; SE 0.01) and emergency department visits (ME 0.30; SE 0.04) through year 1; increased prescriptions (ME 1.45; SE 0.08, age 0) (ME 0.69; SE 0.11, age 1 year) through year 2; and increased outpatient encounters (ME 20.13; SE 0.54, age 0) (ME 3.95; SE 0.62, age 1 year) (ME 2.90; SE 1.11, age 2 years) through year 3 after adjusting for potential confounders (P < .01 for all). Beyond the third year, health care utilization was similar between those with and without NAS. CONCLUSIONS Children with a diagnosis of NAS have greater health care utilization through the third year of life. These differences resolve by the fourth year. Our results suggest resolution of disparities may be due to shifts in developmental health management in school-age children and inability to track relevant diagnoses in a health care database.
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Affiliation(s)
- Tammy E Corr
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA
| | - Xueyi Xing
- Evidence-to-Impact Collaborative, Social Science Research Institute, Penn State University, State College, PA
| | - Guodong Liu
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
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Yen E, Murphy HJ, Friedman H, Lucke AM, Rodday AM. Neonatal abstinence syndrome practice variations across pediatric subspecialty. J Perinatol 2021; 41:1512-1514. [PMID: 32968221 PMCID: PMC7985043 DOI: 10.1038/s41372-020-00831-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 08/22/2020] [Accepted: 09/14/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Elizabeth Yen
- Department of Pediatrics, Tufts Medical Center, Boston, MA, USA.
| | - Heidi J Murphy
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Hayley Friedman
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Ashley M Lucke
- Department of Pediatrics, University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Angie Mae Rodday
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
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Bhandary S, Lambeth T, Holmes A, Pylipow M. Using buprenorphine to treat neonatal abstinence syndrome: a quality improvement study. J Perinatol 2021; 41:1480-1486. [PMID: 33758394 DOI: 10.1038/s41372-021-01035-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 02/05/2021] [Accepted: 03/01/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess if treating neonatal abstinence syndrome (NAS) with sublingual buprenorphine (SLB) would decrease the mean duration of therapy (DOT) and length of birth hospital stay (LOS). STUDY DESIGN Conducted at a tertiary hospital with >6000 annual deliveries and a 2% incidence of NAS, a quality improvement study using plan-do-study-act (PDSA) cycles were utilized. Outcomes were measured using statistical process control (SPC) charts. RESULTS All NAS patients were treated with SLB, no adverse reactions were reported and the need for an adjunctive agent was static. SPC charts demonstrated decreased variability and special cause variation indicating a reduction in both DOT (from 14.5 to 8.5 days) and LOS (from 18.5 to 13 days).
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Affiliation(s)
- Sagar Bhandary
- Wake Forest University Baptist Medical Center, Brenner Children's Hospital, Winston-Salem, NC, USA.
| | - Tinisha Lambeth
- Wake Forest University Baptist Medical Center, Brenner Children's Hospital, Winston-Salem, NC, USA.,Novant Health Forsyth Medical Center, Winston-Salem, NC, USA
| | - Amy Holmes
- Novant Health Forsyth Medical Center, Winston-Salem, NC, USA
| | - Mary Pylipow
- Wake Forest University Baptist Medical Center, Brenner Children's Hospital, Winston-Salem, NC, 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 a sedative versus control (placebo, usual treatment or non-pharmacological treatment) for NAS due to withdrawal from opioids and determine which type of sedative is most effective and safe for NAS due to withdrawal from opioids. SEARCH METHODS We ran an updated search on 17 September 2020 in CENTRAL via CRS Web and MEDLINE via Ovid. We searched clinical trials databases, conference proceedings and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA We included trials enrolling infants with NAS born to mothers with an opioid dependence with more than 80% follow-up and using randomised, quasi-randomised and cluster-randomised allocation to sedative or control. DATA COLLECTION AND ANALYSIS Three review authors assessed trial eligibility and risk of bias, and independently extracted data. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS We included 10 trials (581 infants) with NAS secondary to maternal opioid use in pregnancy. There were multiple comparisons of different sedatives and regimens. There were limited data available for use in sensitivity analysis of studies at low risk of bias. Phenobarbital versus supportive care: one study reported there may be little or no difference in treatment failure with phenobarbital and supportive care versus supportive care alone (risk ratio (RR) 2.73, 95% confidence interval (CI) 0.94 to 7.94; 62 participants; very low-certainty evidence). No infant had a clinical seizure. The study did not report mortality, neurodevelopmental disability and adverse events. There may be an increase in days' hospitalisation and treatment from use of phenobarbital (hospitalisation: mean difference (MD) 20.80, 95% CI 13.64 to 27.96; treatment: MD 17.90, 95% CI 11.98 to 23.82; both 62 participants; very low-certainty evidence). Phenobarbital versus diazepam: there may be a reduction in treatment failure with phenobarbital versus diazepam (RR 0.39, 95% CI 0.24 to 0.62; 139 participants; 2 studies; low-certainty evidence). The studies did not report mortality, neurodevelopmental disability and adverse events. One study reported there may be little or no difference in days' hospitalisation and treatment (hospitalisation: MD 3.89, 95% CI -1.20 to 8.98; 32 participants; treatment: MD 4.30, 95% CI -0.73 to 9.33; 31 participants; both low-certainty evidence). Phenobarbital versus chlorpromazine: there may be a reduction in treatment failure with phenobarbital versus chlorpromazine (RR 0.55, 95% CI 0.33 to 0.92; 138 participants; 2 studies; very low-certainty evidence), and no infant had a seizure. The studies did not report mortality and neurodevelopmental disability. One study reported there may be little or no difference in days' hospitalisation (MD 7.00, 95% CI -3.51 to 17.51; 87 participants; low-certainty evidence) and 0/100 infants had an adverse event. Phenobarbital and opioid versus opioid alone: one study reported no infants with treatment failure and no clinical seizures in either group (low-certainty evidence). The study did not report mortality, neurodevelopmental disability and adverse events. One study reported there may be a reduction in days' hospitalisation for infants treated with phenobarbital and opioid (MD -43.50, 95% CI -59.18 to -27.82; 20 participants; low-certainty evidence). Clonidine and opioid versus opioid alone: one study reported there may be little or no difference in treatment failure with clonidine and dilute tincture of opium (DTO) versus DTO alone (RR 0.09, 95% CI 0.01 to 1.59; 80 participants; very low-certainty evidence). All five infants with treatment failure were in the DTO group. There may be little or no difference in seizures (RR 0.14, 95% CI 0.01 to 2.68; 80 participants; very low-certainty evidence). All three infants with seizures were in the DTO group. There may be little or no difference in mortality after discharge (RR 7.00, 95% CI 0.37 to 131.28; 80 participants; very low-certainty evidence). All three deaths were in the clonidine and DTO group. The study did not report neurodevelopmental disability. There may be little or no difference in days' treatment (MD -4.00, 95% CI -8.33 to 0.33; 80 participants; very low-certainty evidence). One adverse event occurred in the clonidine and DTO group. There may be little or no difference in rebound NAS after stopping treatment, although all seven cases were in the clonidine and DTO group. Clonidine and opioid versus phenobarbital and opioid: there may be little or no difference in treatment failure (RR 2.27, 95% CI 0.98 to 5.25; 2 studies, 93 participants; very low-certainty evidence). One study reported one infant in the clonidine and morphine group had a seizure, and there were no infant mortalities. The studies did not report neurodevelopmental disability. There may be an increase in days' hospitalisation and days' treatment with clonidine and opioid versus phenobarbital and opioid(hospitalisation: MD 7.13, 95% CI 6.38 to 7.88; treatment: MD 7.57, 95% CI 3.97 to 11.17; both 2 studies, 91 participants; low-certainty evidence). There may be little or no difference in adverse events (RR 1.55, 95% CI 0.44 to 5.40; 2 studies, 93 participants; very low-certainty evidence). However, there was oversedation only in the phenobarbital and morphine group; and hypotension, rebound hypertension and rebound NAS only in the clonidine and morphine group. AUTHORS' CONCLUSIONS There is very low-certainty evidence that phenobarbital increases duration of hospitalisation and treatment, but reduces days to regain birthweight and duration of supportive care each day compared to supportive care alone. There is low-certainty evidence that phenobarbital reduces treatment failure compared to diazepam and very low-certainty evidence that phenobarbital reduces treatment failure compared to chlorpromazine. There is low-certainty evidence of an increase in days' hospitalisation and days' treatment with clonidine and opioid compared to phenobarbital and opioid. There are insufficient data to determine the safety and incidence of adverse events for infants treated with combinations of opioids and sedatives including phenobarbital and 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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Proctor-Williams K, Louw B. Cleft Lip and/or Palate in Infants Prenatally Exposed to Opioids. Cleft Palate Craniofac J 2021; 59:513-521. [PMID: 33960243 DOI: 10.1177/10556656211013687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To determine the prevalence and odds ratios for cleft lip and/or palate (CL/P) among infants prenatally exposed to opioids with or without neonatal opioid withdrawal syndrome (NOWS). DESIGN This study represents an exploratory, retrospective cohort study design of newborn medical health records from 2011 to 2016. SETTING Records were drawn from a regional health system located in South Central Appalachia. POPULATION AND STUDY SAMPLE The original population yielded 3 cohorts of infants: (1) infants with opioid exposure (OE) but not requiring pharmacological intervention (OE; N = 168); (2) infants with NOWS requiring pharmacological intervention (N = 294); and (3) infants with no opioid exposure (NOE; N = 16 090), the primary comparison group. MAIN OUTCOME Infants in the NOWS and OE groups showed significantly increased prevalence and odds ratios for CL/P when compared to those in the NOE group. RESULTS Prevalence rates per 1000 live births for infants with OE (35.71) and infants with NOWS (6.80) were significantly higher than those for infants with NOE (1.37). Comparison of infants with OE to the NOE group revealed significantly increased odds for CL/P, isolated cleft palate (CP), cleft lip (CL), and cleft lip and palate (CLP) (27.05, 41.81, 19.26, 19.37, respectively; all Ps < .008). The odds ratios for infants with NOWS compared to the NOE group were significantly higher for CL/P and CP (5.00 and 10.98, respectively; Ps < .03) but not for CL and CLP. CONCLUSION The results provide additional evidence that prenatal OE should be considered among the critical environmental risk factors that can contribute to CL/P.
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Affiliation(s)
- Kerry Proctor-Williams
- Department Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City, TN, USA
| | - Brenda Louw
- Department Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City, TN, USA
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Oji-Mmuo CN, Jones AN, Wu EY, Speer RR, Palmer T. Clinical care of neonates undergoing opioid withdrawal in the immediate postpartum period. Neurotoxicol Teratol 2021; 86:106978. [PMID: 33838247 DOI: 10.1016/j.ntt.2021.106978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 02/15/2021] [Accepted: 03/30/2021] [Indexed: 11/19/2022]
Abstract
As the opioid epidemic escalates in westernized countries around the world, chronic opioid use during pregnancy has become a growing public health issue. There are increasing concerns that chronic maternal opioid use might adversely affect the developing fetal brain. Furthermore, the sudden discontinuation of the trans-placental opioid supply at birth puts newborns at acute risk for neonatal opioid withdrawal syndrome (NOWS). NOWS is a multi-system disorder that has been identified in approximately 50-80% of neonates exposed to opioids due to chronic maternal use. Clinically, NOWS affects the central and autonomic nervous systems as well as the gastrointestinal and respiratory tracts. The clinical features of NOWS include hyperirritability, high-pitched crying, restlessness, tremors, poor sleep, agitation, seizures, sweating, fever, poor feeding, regurgitation, diarrhea, and tachypnea. NOWS is currently diagnosed using a clinical scoring tool followed by toxicological confirmation of the presence of opioids in meconium or tissue specimens. The first-line treatments for NOWS are non-pharmacologic comfort measures. If these measures fail, neonates may be treated with opioids and/or sedatives. Since the severity of NOWS can be highly variable, it is quite difficult to predict which opioid-exposed neonates will require pharmacotherapy and prolonged hospitalization. Factors associated with maternal polysubstance use, including the use of illicit substances and tobacco, have been associated with the increased severity and duration of NOWS. Since neonates with NOWS are at increased risk for long-term adverse neurodevelopmental outcomes, ongoing monitoring beyond the neonatal period is essential.
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Affiliation(s)
- Christiana N Oji-Mmuo
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State College of Medicine, Hershey, PA, USA.
| | - Antoinette N Jones
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Emma Y Wu
- Penn State College of Medicine, Hershey, PA, USA
| | - Rebecca R Speer
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Timothy Palmer
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State College of Medicine, Hershey, PA, USA
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43
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Peacock-Chambers E, Paterno MT, Kiely D, Fioroni T, Byatt N, Friedmann PD. Engagement in perinatal outpatient services among women in recovery from opioid use disorders. Subst Abus 2021; 42:1022-1029. [PMID: 33798013 DOI: 10.1080/08897077.2021.1904091] [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] [Indexed: 10/21/2022]
Abstract
Background: Despite being highly motivated to recover, pregnant and postpartum women with opioid use disorders (OUD) are at high risk of relapse and death. While many services mitigate this risk, engagement in voluntary, outpatient services remains low. Our aim was to understand the experiences of and factors influencing outpatient service engagement during the perinatal period among women in recovery from OUD. Methods: We conducted semi-structured interviews about perinatal experiences engaging with outpatient services, with 20 women in recovery aged 22-46 years who had children between 6 months and 10 years old. Interviews were audio-recorded, transcribed, coded, and analyzed using conventional content analysis. Results: Women described a continuum of 'collaborative engagement' experiences, defined by the extent to which they perceived their providers or service organizations were invested in their journeys as a partners and advocates. The ability to achieve collaborative engagement depended upon two factors: (1) the woman's transformational development as a mother and woman in recovery, and (2) her perception of the providers' ability to meet her multifaceted needs. Conclusions: Women in recovery from OUD may experience deeper engagement in voluntary outpatient perinatal services when they perceive that their providers are invested and collaboratively engaging in their recovery and personal growth. Future research should test whether collaborative engagement improves service retention.Abbreviations: IPV: Intimate Partner Violence; OUD: opioid use disorder.
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Affiliation(s)
- Elizabeth Peacock-Chambers
- Department of Pediatrics, University of Massachusetts Medical School-Baystate, Springfield, MA, USA.,Institute for Healthcare Delivery and Population Science, Springfield, MA, USA, USA
| | - Mary T Paterno
- College of Nursing, University of Massachusetts, Amherst, MA, USA
| | - Daniel Kiely
- School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA, USA
| | | | - Nancy Byatt
- Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, USA
| | - Peter D Friedmann
- Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA, USA
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44
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Kim HM, Bone RM, McNeill B, Lee SJ, Gillon G, Woodward LJ. Preschool Language Development of Children Born to Women with an Opioid Use Disorder. CHILDREN-BASEL 2021; 8:children8040268. [PMID: 33807265 PMCID: PMC8066299 DOI: 10.3390/children8040268] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 03/26/2021] [Accepted: 03/28/2021] [Indexed: 12/15/2022]
Abstract
Increasing evidence suggests that prenatal exposure to opioids may affect brain development, but limited data exist on the effects of opioid-exposure on preschool language development. Our study aimed to characterize the nature and prevalence of language problems in children prenatally exposed to opioids, and the factors that support or hinder language acquisition. A sample of 100 children born to pregnant women in methadone maintenance treatment and 110 randomly identified non-exposed children were studied from birth to age 4.5 years. At 4.5 years, 89 opioid-exposed and 103 non-exposed children completed the preschool version of the Clinical Evaluation of Language Fundamentals (CELF-P) as part of a comprehensive neurodevelopmental assessment. Children prenatally exposed to opioids had poorer receptive and expressive language outcomes at age 4.5 years compared to non-opioid exposed children. After adjustment for child sex, maternal education, other pregnancy substance use, maternal pregnancy nutrition and prenatal depression, opioid exposure remained a significant independent predictor of children’s total CELF-P language score. Examination of a range of potential intervening factors showed that a composite measure of the quality of parenting and home environment at age 18 months and early childhood education participation at 4.5 years were important positive mediators.
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Affiliation(s)
- Hyun Min Kim
- School of Health Sciences, University of Canterbury, Christchurch 8041, New Zealand; (R.M.B.); (S.J.L.); (L.J.W.)
- Child Well-Being Research Institute, University of Canterbury, Christchurch 8041, New Zealand; (B.M.); (G.G.)
- Correspondence:
| | - Reisha M. Bone
- School of Health Sciences, University of Canterbury, Christchurch 8041, New Zealand; (R.M.B.); (S.J.L.); (L.J.W.)
| | - Brigid McNeill
- Child Well-Being Research Institute, University of Canterbury, Christchurch 8041, New Zealand; (B.M.); (G.G.)
- School of Teacher Education, University of Canterbury, Christchurch 8041, New Zealand
| | - Samantha J. Lee
- School of Health Sciences, University of Canterbury, Christchurch 8041, New Zealand; (R.M.B.); (S.J.L.); (L.J.W.)
- Child Well-Being Research Institute, University of Canterbury, Christchurch 8041, New Zealand; (B.M.); (G.G.)
| | - Gail Gillon
- Child Well-Being Research Institute, University of Canterbury, Christchurch 8041, New Zealand; (B.M.); (G.G.)
| | - Lianne J. Woodward
- School of Health Sciences, University of Canterbury, Christchurch 8041, New Zealand; (R.M.B.); (S.J.L.); (L.J.W.)
- Child Well-Being Research Institute, University of Canterbury, Christchurch 8041, New Zealand; (B.M.); (G.G.)
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45
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Shrestha S, Roberts MH, Maxwell JR, Leeman LM, Bakhireva LN. Post-discharge healthcare utilization in infants with neonatal opioid withdrawal syndrome. Neurotoxicol Teratol 2021; 86:106975. [PMID: 33766722 DOI: 10.1016/j.ntt.2021.106975] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 03/10/2021] [Accepted: 03/15/2021] [Indexed: 12/15/2022]
Abstract
The opioid epidemic in the United States has led to a significant increase in the incidence of neonatal opioid withdrawal syndrome (NOWS); however, the understanding of long-term consequences of NOWS is limited. The objective of this study was to evaluate post-discharge healthcare utilization in infants with NOWS and examine the association between NOWS severity and healthcare utilization. A retrospective cohort design was used to ascertain healthcare utilization in the first year after birth-related discharge using the CERNER Health Facts® database. ICD-9/ICD-10 diagnostic codes were used to identify live births and to classify infants into two study groups: NOWS and uncomplicated births (a 25% random sample). Evaluated outcomes included rehospitalization, emergency department (ED) visits within 30-days and one-year after discharge, and a composite one-year utilization event (either hospitalization or emergency department visit during that year). NOWS severity was operationalized as pharmacologic treatment, length of hospitalization, and medical conditions often associated with NOWS. In 3,526 infants with NOWS (restricted to gestational age ≥ 33 weeks), NOWS severity was associated with an increase in composite one-year utilization (OR: 1.1; 95% CI: 1.04-1.2) after adjusting for prematurity, sepsis, jaundice, use of antibiotics, infant sex, insurance status, race, hospital bed size, year of birth, and census division. In a subset of full-term infants (3008 with NOWS and 88,452 uncomplicated births), having a NOWS diagnosis was associated with higher odds of a 30-day (OR: 1.6; 95% CI: 1.03-2.4) and one-year rehospitalization (OR: 1.6; 95% CI: 1.1-2.4) after adjusting for infant sex, race, type of medical insurance, hospital location, census division, year of primary encounter, hospital bed size, and medical conditions. This study found higher healthcare utilization during the first year of life in infants diagnosed with NOWS, especially those with severe NOWS. Findings suggest a need for closer post-discharge follow-up and management of infants with NOWS.
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Affiliation(s)
- Shikhar Shrestha
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA (Current Affiliation), United States of America; Department of Pharmacy Practice and Administrative Sciences, College of Pharmacy, University of New Mexico, Albuquerque, NM (Institution where the research was carried out), United States of America.
| | - Melissa H Roberts
- Department of Pharmacy Practice and Administrative Sciences, College of Pharmacy, University of New Mexico, Albuquerque, NM (Institution where the research was carried out), United States of America
| | - Jessie R Maxwell
- Department of Pediatrics, University of New Mexico, Albuquerque, NM, United States of America
| | - Lawrence M Leeman
- Department of Family and Community Medicine, University of New Mexico, Albuquerque, NM, United States of America
| | - Ludmila N Bakhireva
- Department of Pharmacy Practice and Administrative Sciences, College of Pharmacy, University of New Mexico, Albuquerque, NM (Institution where the research was carried out), United States of America; Department of Family and Community Medicine, University of New Mexico, Albuquerque, NM, United States of America; Division of Epidemiology, Biostatistics and Preventive Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, NM, United States of America
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46
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Pandey R, Kanike N, Ibrahim M, Swarup N, Super DM, Groh-Wargo S, Kumar D. Lactose-free infant formula does not change outcomes of neonatal abstinence syndrome (NAS): a randomized clinical trial. J Perinatol 2021; 41:598-605. [PMID: 32868858 DOI: 10.1038/s41372-020-00797-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 08/16/2020] [Accepted: 08/20/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To determine if lactose-free formula, compared to lactose-containing formula, decreases the cumulative morphine dose required to treat neonatal abstinence syndrome (NAS). STUDY DESIGN In a double-blind clinical trial, we randomized 74 infants (36-42 weeks gestation) at risk for developing NAS due to in-utero exposure to opioids to receive either lactose-free (Similac Sensitive®) or lactose-containing (Similac Advance®) infant formula. The primary outcome measure was the cumulative dose of morphine used for the treatment of NAS during the first 14 days of life. RESULTS Data on 69 (4 withdrew consent and 1 ineligible)/74 randomized infants were analyzed. Patient characteristics between the infant groups fed lactose-free (n = 34) vs. lactose-containing (n = 35) infant formula were similar except more common maternal heroin abuse in the latter group (p = 0.013). Cumulative morphine dose (20.7 ± 19.8 vs. 23 ± 23.5 mg, p = 0.61) between the two groups were similar. CONCLUSION Lactose-free vs. lactose-containing infant formula did not change the outcomes of infants with NAS.
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Affiliation(s)
- Rajesh Pandey
- Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA.,Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Neelakanta Kanike
- Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA.,Pediatrics, Deaconess Women's Hospital, Newburgh, IN, USA
| | - Mugahid Ibrahim
- Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA.,Department of Pediatrics, Cork University Maternity Hospital (CUMH), Cork, Ireland
| | - Namita Swarup
- Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Dennis M Super
- Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Sharon Groh-Wargo
- Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Deepak Kumar
- Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA.
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47
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Alipio JB, Brockett AT, Fox ME, Tennyson SS, deBettencourt CA, El-Metwally D, Francis NA, Kanold PO, Lobo MK, Roesch MR, Keller A. Enduring consequences of perinatal fentanyl exposure in mice. Addict Biol 2021; 26:e12895. [PMID: 32187805 PMCID: PMC7897444 DOI: 10.1111/adb.12895] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 02/28/2020] [Accepted: 02/29/2020] [Indexed: 12/14/2022]
Abstract
Opioid use by pregnant women is an understudied consequence associated with the opioid epidemic, resulting in a rise in the incidence of neonatal opioid withdrawal syndrome (NOWS) and lifelong neurobehavioral deficits that result from perinatal opioid exposure. There are few preclinical models that accurately recapitulate human perinatal drug exposure and few focus on fentanyl, a potent synthetic opioid that is a leading driver of the opioid epidemic. To investigate the consequences of perinatal opioid exposure, we administered fentanyl to mouse dams in their drinking water throughout gestation and until litters were weaned at postnatal day (PD) 21. Fentanyl-exposed dams delivered smaller litters and had higher litter mortality rates compared with controls. Metrics of maternal care behavior were not affected by the treatment, nor were there differences in dams' weight or liquid consumption throughout gestation and 21 days postpartum. Twenty-four hours after weaning and drug cessation, perinatal fentanyl-exposed mice exhibited signs of spontaneous somatic withdrawal behavior and sex-specific weight fluctuations that normalized in adulthood. At adolescence (PD 35), they displayed elevated anxiety-like behaviors and decreased grooming, assayed in the elevated plus maze and sucrose splash tests. Finally, by adulthood (PD 55), they displayed impaired performance in a two-tone auditory discrimination task. Collectively, our findings suggest that perinatal fentanyl-exposed mice exhibit somatic withdrawal behavior and change into early adulthood reminiscent of humans born with NOWS.
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Affiliation(s)
- Jason B. Alipio
- Department of Anatomy & Neurobiology, Program in Neuroscience, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Adam T. Brockett
- Department of Psychology, University of Maryland, College Park, MD, USA
- Program in Neuroscience and Cognitive Science, University of Maryland, College Park, MD, USA
| | - Megan E. Fox
- Department of Anatomy & Neurobiology, Program in Neuroscience, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Stephen S. Tennyson
- Department of Psychology, University of Maryland, College Park, MD, USA
- Program in Neuroscience and Cognitive Science, University of Maryland, College Park, MD, USA
| | | | - Dina El-Metwally
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nikolas A. Francis
- Department of Biology, University of Maryland, College Park, MD, USA
- Institute for Systems Research, A. James Clark School of Engineering, University of Maryland, College Park, MD, USA
| | - Patrick O. Kanold
- Department of Biology, University of Maryland, College Park, MD, USA
- Institute for Systems Research, A. James Clark School of Engineering, University of Maryland, College Park, MD, USA
| | - Mary Kay Lobo
- Department of Anatomy & Neurobiology, Program in Neuroscience, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Matthew R. Roesch
- Department of Psychology, University of Maryland, College Park, MD, USA
- Program in Neuroscience and Cognitive Science, University of Maryland, College Park, MD, USA
| | - Asaf Keller
- Department of Anatomy & Neurobiology, Program in Neuroscience, University of Maryland School of Medicine, Baltimore, MD, USA
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48
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Neonatal Opioid Withdrawal Syndrome (NOWS): A Transgenerational Echo of the Opioid Crisis. Cold Spring Harb Perspect Med 2021; 11:cshperspect.a039669. [PMID: 32229609 DOI: 10.1101/cshperspect.a039669] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The incidence of neonatal opioid withdrawal syndrome (NOWS) has increased substantially in the setting of the opioid epidemic, a major public health problem in the United States. At present, NOWS has commonly used assessment and treatment protocols, but new protocols have questioned old practices. However, because of limited access to opioid use disorder (OUD) treatment and socioeconomic factors, many pregnant (and postpartum) women with OUD do not receive treatment. The pathophysiology of NOWS is not completely understood, although limited research studies have been conducted in humans and animals to better understand its etiology. Moreover, there is evidence that epigenetic and genetic factors play a role in the development of NOWS, but further study is needed. Animal models have suggested that there are deleterious effects of in utero opioid exposure later in life. Clinical research has revealed the harmful long-term sequelae of NOWS, with respect to cognitive function and childhood development. Many psychiatric disorders begin during adolescence, so as infants born with NOWS approach adolescence, additional clinical and molecular studies are warranted to identify biologic and psychosocial risk factors and long-term effects of NOWS. Additionally, access to specialized OUD treatment for pregnant women must be more readily available in the United States, especially in rural areas.
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49
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Olsen M. Prevention of Neonatal Abstinence Syndrome in an Outpatient Prenatal Buprenorphine Tapering Program. South Med J 2021; 113:553-558. [PMID: 33140108 DOI: 10.14423/smj.0000000000001164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Many addicted pregnant patients receiving buprenorphine medication-assisted therapy (MAT) wish to discontinue this medication while pregnant. This study was undertaken to determine whether outpatient detoxification from buprenorphine during pregnancy is safe and effective when confirmed with postdetoxification urine drug screens (UDSs). METHODS This case series reports the maternal and neonatal outcomes for 21 patients who ended MAT with buprenorphine while pregnant. A retrospective chart review of both maternal and newborn electronic medical records was performed to obtain results. Newborn neonatal abstinence syndrome (NAS) diagnosis, need for morphine, maternal safety and fetal/newborn complications were assessed. Maternal sobriety was documented with UDSs at the time of admission for delivery. Umbilical cord blood also was assessed for substances of abuse. An additional 182 pregnant women who lowered their buprenorphine doses but did not decide to end MAT were assessed via routine quality assurance methods. RESULTS None of the women who stopped buprenorphine during their pregnancy as confirmed by UDSs and umbilical cord sampling delivered neonates who had NAS. Eleven patients ended MAT with medical assistance and 10 ended MAT without medical assistance. No overdoses were reported for the 182 additional pregnant patients who indicated an intention to taper buprenorphine dosage while pregnant but who did not decide to end MAT; the neonatal benefits were obtained without any identified maternal harm. CONCLUSIONS The neonates of pregnant women enrolled in an outpatient buprenorphine MAT tapering program who are able to completely stop taking buprenorphine (as documented by negative urinary drug screen) are very unlikely to have NAS. Further research will be important.
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Affiliation(s)
- Martin Olsen
- From the Department of Obstetrics and Gynecology, Quillen College of Medicine, East Tennessee State University, Johnson City
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50
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Skumlien M, Ibsen IO, Kesmodel US, Nygaard E. Sex Differences in Early Cognitive Development After Prenatal Exposure to Opioids. J Pediatr Psychol 2021; 45:475-485. [PMID: 32324876 PMCID: PMC7233842 DOI: 10.1093/jpepsy/jsaa008] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 02/04/2020] [Accepted: 02/10/2020] [Indexed: 01/08/2023] Open
Abstract
Objective Prenatal opioid exposure has been linked with impaired cognitive development, with boys potentially at elevated risk. In the present study, we examined cognitive and language development of children prenatally exposed to opioids, with an additional focus on sex differences. Methods A sample of 378 children (n = 194 girls and n = 184 boys) aged 1.2–42.8 months was drawn from the Danish Family Outpatient Clinic database. Developmental outcomes were assessed using the Bayley-III cognitive and language scales, and substance exposure was determined with urine screening and/or verbal report. Children exposed to opioids (n = 94) were compared to children with no prenatal substance exposure (n = 38), and children exposed to alcohol (n = 131) or tobacco (n = 115). Group and sex differences were investigated with separate linear mixed models for each Bayley scale, controlling for concurrent cannabis exposure. Results There were significantly reduced scores in opioid-exposed boys compared to boys with no prenatal substance exposure, but no difference between opioid-exposed and nonexposed girls. Additionally, alcohol-exposed boys had lower cognitive scores than nonexposed boys, and alcohol-exposed girls had lower scores on both scales compared to opioid-exposed girls. There were otherwise no significant differences according to group, sex, or scale. Conclusions The present findings indicate poorer cognitive and language development in boys after prenatal opioid exposure. As academic performance is rooted in cognitive functioning, long-term follow-up might be necessary for exposed children.
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Affiliation(s)
| | - Inge Olga Ibsen
- Department of Obstetrics and Gynaecology, Odense University Hospital
| | - Ulrik Schiøler Kesmodel
- Department of Obstetrics and Gynaecology, Aalborg University Hospital.,Department of Clinical Medicine, Aalborg University
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