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Wingfield KK, Misic T, Jain K, McDermott CS, Abney NM, Richardson KT, Rubman MB, Beierle JA, Miracle SA, Sandago EJ, Baskin BM, Lynch WB, Borrelli KN, Yao EJ, Wachman EM, Bryant CD. The ultrasonic vocalization (USV) syllable profile during neonatal opioid withdrawal and a kappa opioid receptor component to increased USV emissions in female mice. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.07.02.601766. [PMID: 39005445 PMCID: PMC11244951 DOI: 10.1101/2024.07.02.601766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Abstract
RATIONALE Opioid use during pregnancy can lead to negative infant health outcomes, including neonatal opioid withdrawal syndrome (NOWS). NOWS comprises gastrointestinal, autonomic nervous system, and neurological dysfunction that manifest during spontaneous withdrawal. Variability in NOWS severity necessitates a more individualized treatment approach. Ultrasonic vocalizations (USVs) in neonatal mice are emitted in isolation as a stress response and are increased during opioid withdrawal, thus modeling a negative affective state that can be utilized to test new treatments. OBJECTIVES We sought to identify the behavioral and USV profile, brainstem transcriptomic adaptations, and role of kappa opioid receptors in USVs during neonatal opioid withdrawal. METHODS We employed a third trimester-approximate opioid exposure model, where neonatal inbred FVB/NJ pups were injected twice-daily with morphine (10mg/kg, s.c.) or saline (0.9%, 20 ul/g, s.c.) from postnatal day(P) 1 to P14. This protocol induces reduced weight gain, hypothermia, thermal hyperalgesia, and increased USVs during spontaneous morphine withdrawal. RESULTS On P14, there were increased USV emissions and altered USV syllables during withdrawal, including an increase in Complex 3 syllables in FVB/NJ females (but not males). Brainstem bulk mRNA sequencing revealed an upregulation of the kappa opioid receptor (Oprk1), which contributes to withdrawal-induced dysphoria. The kappa opioid receptor (KOR) antagonist, nor-BNI (30 mg/kg, s.c.), significantly reduced USVs in FVB/NJ females, but not males during spontaneous morphine withdrawal. Furthermore, the KOR agonist, U50,488h (0.625 mg/kg, s.c.), was sufficient to increase USVs on P10 (both sexes) and P14 (females only) in FVB/NJ mice. CONCLUSIONS We identified an elevated USV syllable, Complex 3, and a female-specific recruitment of the dynorphin/KOR system in increased USVs associated with neonatal opioid withdrawal severity.
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Singh R, Melvin P, Wachman EM, Rothstein R, Schiff DM, Murzycki J, VanVleet M, Gupta M, Davis JM. Short term outcomes of neonatal opioid withdrawal syndrome: a comparison of two approaches. J Perinatol 2024; 44:1137-1145. [PMID: 38565652 DOI: 10.1038/s41372-024-01953-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 03/14/2024] [Accepted: 03/20/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVE To evaluate outcomes in opioid exposed neonates (OENs) assessed by the Eat, Sleep, Console (ESC) tool compared to the Finnegan Neonatal Abstinence Scoring System (FNASS). METHODS Retrospective analysis of a statewide database of OENs from 2017 to 2020 with birthing hospitals classified based on the assessment tool used. Four main outcomes were examined using multivariable and Poisson logistic regression models. RESULTS Of 2375 OENs, 42.1% received pharmacotherapy (PT) with a consistent decrease in PT, length of treatment (LOT), and length of stay (LOS) over the study period. There was no change in use of mother's own milk (MoM). While outcomes were significantly associated with several specific variables, there were no differences in outcomes between assessment methods. CONCLUSION While there was a significant decrease over time in PT, LOT, and LOS, improvements were independent of the assessment tool used and likely related to the increased use of non-pharmacologic care.
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Affiliation(s)
- Rachana Singh
- Department of Pediatrics, Tufts University School of Medicine, Boston, MA, USA.
| | - Patrice Melvin
- Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston, MA, USA
| | - Elisha M Wachman
- Department of Pediatrics, Boston Medical Center, Boston, MA, USA
| | - Robert Rothstein
- Department of Pediatrics, Baystate Children's Hospital, Springfield, MA, USA
| | - Davida M Schiff
- Divisions of Newborn Medicine and General Academic Pediatrics, Massachusetts General for Children, Boston, MA, USA
| | - Jennifer Murzycki
- Department of Pediatrics, Tufts University School of Medicine, Boston, MA, USA
| | - Marcia VanVleet
- Division of Newborn Medicine, Baystate Franklin Medical Center, Greenfield, MA, USA
| | - Munish Gupta
- Division of Newborn Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jonathan M Davis
- Department of Pediatrics, Tufts University School of Medicine, Boston, MA, USA
- The Tufts Clinical and Translational Science Institute, Boston, MA, USA
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van Hoogdalem MW, Tanaka R, Johnson TN, Vinks AA, Mizuno T. Development and Verification of a Full Physiologically Based Pharmacokinetic Model for Sublingual Buprenorphine in Healthy Adult Volunteers that Accounts for Nonlinear Bioavailability. Drug Metab Dispos 2024; 52:785-796. [PMID: 38769016 PMCID: PMC11257693 DOI: 10.1124/dmd.124.001643] [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: 01/03/2024] [Revised: 05/09/2024] [Accepted: 05/13/2024] [Indexed: 05/22/2024] Open
Abstract
Sublingual buprenorphine is used for opioid use disorder and neonatal opioid withdrawal syndrome. The study aimed to develop a full physiologically based pharmacokinetic (PBPK) model that can adequately describe dose- and formulation-dependent bioavailability of buprenorphine. Simcyp (v21.0) was used for model construction. Four linear regression models (i.e., untransformed or log transformed for dose or proportion sublingually absorbed) were explored to describe sublingual absorption of buprenorphine across dose. Published clinical trial data not used in model development were used for verification. The PBPK model's predictive performance was deemed adequate if the geometric means of ratios between predicted and observed (P/O) area under the curve (AUC), peak concentration (Cmax), and time to reach Cmax (Tmax) fell within the 1.25-fold prediction error range. Sublingual buprenorphine absorption was best described by a regression model with logarithmically transformed dose. By integrating this nonlinear absorption profile, the PBPK model adequately predicted buprenorphine pharmacokinetics (PK) following administration of sublingual tablets and solution across a dose range of 2-32 mg, with geometric mean (95% confidence interval) P/O ratios for AUC and Cmax equaling 0.99 (0.86-1.12) and 1.24 (1.09-1.40), respectively, and median (5th to 95th percentile) for Tmax equaling 1.11 (0.69-1.57). A verified PBPK model was developed that adequately predicts dose- and formulation-dependent buprenorphine PK following sublingual administration. SIGNIFICANCE STATEMENT: The physiologically based pharmacokinetic (PBPK) model developed in this study is the first to adequately predict dose- and formulation-dependent sublingual buprenorphine pharmacokinetics. Accurate prediction was facilitated by the incorporation of a novel nonlinear absorption model. The developed model will serve as the foundation for maternal-fetal PBPK modeling to predict maternal and fetal buprenorphine exposures to optimize buprenorphine treatment for neonatal opioid withdrawal syndrome.
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Affiliation(s)
- Matthijs W van Hoogdalem
- Division of Translational and Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (M.W.v.H., R.T., A.A.V., T.M.); James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, Ohio (M.W.v.H.); Certara UK Limited, Sheffield, United Kingdom (T.N.J.); and Department of Pediatrics (A.A.V., T.M.) and Center for Addiction Research (A.A.V., T.M.), College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Ryota Tanaka
- Division of Translational and Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (M.W.v.H., R.T., A.A.V., T.M.); James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, Ohio (M.W.v.H.); Certara UK Limited, Sheffield, United Kingdom (T.N.J.); and Department of Pediatrics (A.A.V., T.M.) and Center for Addiction Research (A.A.V., T.M.), College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Trevor N Johnson
- Division of Translational and Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (M.W.v.H., R.T., A.A.V., T.M.); James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, Ohio (M.W.v.H.); Certara UK Limited, Sheffield, United Kingdom (T.N.J.); and Department of Pediatrics (A.A.V., T.M.) and Center for Addiction Research (A.A.V., T.M.), College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Alexander A Vinks
- Division of Translational and Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (M.W.v.H., R.T., A.A.V., T.M.); James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, Ohio (M.W.v.H.); Certara UK Limited, Sheffield, United Kingdom (T.N.J.); and Department of Pediatrics (A.A.V., T.M.) and Center for Addiction Research (A.A.V., T.M.), College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Tomoyuki Mizuno
- Division of Translational and Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (M.W.v.H., R.T., A.A.V., T.M.); James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, Ohio (M.W.v.H.); Certara UK Limited, Sheffield, United Kingdom (T.N.J.); and Department of Pediatrics (A.A.V., T.M.) and Center for Addiction Research (A.A.V., T.M.), College of Medicine, University of Cincinnati, Cincinnati, Ohio
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Lisonkova S, Wen Q, Richter LL, Ting JY, Lyons J, Mitchell-Foster S, Oviedo-Joekes E, Muraca GM, Bayrampour H, Cattoni E, Abrahams R. Neonatal abstinence syndrome and infant mortality and morbidity: a population-based study. Front Pediatr 2024; 12:1394682. [PMID: 39081925 PMCID: PMC11286564 DOI: 10.3389/fped.2024.1394682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 06/20/2024] [Indexed: 08/02/2024] Open
Abstract
Background Infant health among newborns with neonatal abstinence syndrome (NAS) has been understudied. We examined infant mortality and hospitalizations among infants diagnosed with NAS after birth. Methods All live births in British Columbia (BC), Canada, for fiscal years from 2004-2005 to 2019-2020, were included (N = 696,900). NAS was identified based on International Classification of Diseases, version 10, Canadian modification (ICD-10-CA) codes; the outcomes included infant death and hospitalizations during the first year of life, ascertained from BC linked administrative data. Generalized estimating equation models were used to adjust for maternal factors. Results There were 2,439 infants with NAS (3.50 per 1,000 live births). Unadjusted for other factors, infant mortality was 2.5-fold higher in infants with vs. without NAS (7.79 vs. 3.08 per 1,000 live births, respectively) due to increased post-discharge mortality NAS (5.76 vs. 1.34 per 1,000 surviving infants, respectively). These differences diminished after adjustment: adjusted odds ratio (AOR) for infant death was 0.85 [95% confidence interval (CI): 0.52-1.39]; AOR for post-discharge death was 1.75 (95% CI 1.00-3.06). Overall, 22.3% infants with NAS had at least one hospitalization after post-neonatal discharge, this proportion was 10.7% in those without NAS. During the study period, discharge to foster care declined from 49.5% to 20.3% in infants with NAS. Conclusion Unadjusted for other factors, infants with NAS had increased post-discharge infant mortality and hospitalizations during the first year of life. This association diminished after adjustment for adverse maternal and socio-medical conditions. Infants with NAS had a disproportionately higher rate of placement in foster care after birth, although this proportion declined dramatically between 2004/2005 and 2019/2020. These results highlight the importance of implementing integrated care services to support infants born with NAS and their mothers during the first year of life and beyond, even though NAS itself is not independently associated with increased infant mortality.
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Affiliation(s)
- Sarka Lisonkova
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Qi Wen
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Lindsay L. Richter
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Joseph Y. Ting
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Janet Lyons
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Sheona Mitchell-Foster
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
- Northern Medical Program, University of British Columbia, Prince George, BC, Canada
| | - Eugenia Oviedo-Joekes
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Giulia M. Muraca
- Departments of Obstetrics and Gynecology, and Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Hamideh Bayrampour
- Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Eric Cattoni
- Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ronald Abrahams
- Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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Anbalagan S, Anderson V, Favara MT, Stark D, Carola D, Solarin K, Adeniyi-Jones S, Kraft WK, Aghai ZH. Buprenorphine vs. morphine: impact on neonatal opioid withdrawal syndrome (NOWS) outcomes in a single center retrospective study. J Perinatol 2024:10.1038/s41372-024-02046-7. [PMID: 39003405 DOI: 10.1038/s41372-024-02046-7] [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: 02/05/2024] [Revised: 06/27/2024] [Accepted: 07/02/2024] [Indexed: 07/15/2024]
Abstract
OBJECTIVES To compare clinical outcomes for infants with neonatal opioid withdrawal syndrome (NOWS) treated with buprenorphine or morphine. STUDY DESIGN Retrospective study of infants born ≥35 weeks' gestation and admitted to the NICU for NOWS treatment between 2011 and 2022. Length of treatment, length of stay in the hospital, and the need for secondary medications were compared between buprenorphine and morphine treated neonates. Multiple regression analysis was performed, adjusting for baseline differences and confounders. RESULTS 417 neonates were treated with morphine and 232 with buprenorphine. The buprenorphine group had shorter treatment days [-10.8 days; 95% CI: -8.08 to -13.53] and shorter hospital stay [-11.8 days; 95% CI: -8.83 to -14.78]. The buprenorphine group was no more likely to receive phenobarbital or clonidine (26% vs. 29%). CONCLUSION In this large single-center study, buprenorphine was associated with shorter lengths of treatment and hospital stay in the treatment of NOWS compared to morphine.
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Affiliation(s)
- Saminathan Anbalagan
- Deparment of Pediatrics/Neonatology, Thomas Jefferson University/Nemours, Philadelphia, PA, USA.
- Deparment of Pediatrics/Neonatology, University of South Alabama, Mobile, AL, USA.
| | - Victoria Anderson
- Deparment of Pediatrics/Neonatology, Thomas Jefferson University/Nemours, Philadelphia, PA, USA
| | - Michael T Favara
- Deparment of Pediatrics/Neonatology, ChristianaCare Hospital, Newark, DE, USA
| | - Daniela Stark
- Deparment of Pediatrics/Neonatology, Thomas Jefferson University/Nemours, Philadelphia, PA, USA
| | - David Carola
- Deparment of Pediatrics/Neonatology, Thomas Jefferson University/Nemours, Philadelphia, PA, USA
| | - Kolawole Solarin
- Deparment of Pediatrics/Neonatology, Thomas Jefferson University/Nemours, Philadelphia, PA, USA
| | - Susan Adeniyi-Jones
- Deparment of Pediatrics/Neonatology, Thomas Jefferson University/Nemours, Philadelphia, PA, USA
| | - Walter K Kraft
- Department of Pharmacology, Physiology, and Cancer Biology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Zubair H Aghai
- Deparment of Pediatrics/Neonatology, Thomas Jefferson University/Nemours, Philadelphia, PA, USA
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McMillin GA, Morad AW, Boyd JM, Johnson-Davis KL, Metz TD, Smid MC, Krasowski MD. Biological Testing and Interpretation of Laboratory Results Associated with Detecting Newborns with Substance Exposure. Clin Chem 2024; 70:934-947. [PMID: 38549034 DOI: 10.1093/clinchem/hvae018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/02/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Substance use during pregnancy is common, as is biological testing that is intended to help identify prenatal exposures. However, there is no standardized requirement for biological testing with either maternal or newborn specimens, nor is there standardization related to when testing occurs, how frequently testing occurs, what specimen(s) to test, what substances to test for, or how to perform testing. CONTENT We review common specimen types tested to detect maternal and newborn substance exposure with a focus on urine, meconium, and umbilical cord tissue. We also review common analytical methods used to perform testing, including immunoassay, and mass spectrometry platforms. Considerations regarding the utilization of testing relative to the purpose of testing, the drug analyte(s) of interest, the specific testing employed, and the interpretation of results are emphasized to help guide decisions about clinical utilization of testing. We also highlight specific examples of unexpected results that can be used to guide interpretation and appropriate next steps. SUMMARY There are strengths and limitations associated with all approaches to detecting substance exposure in pregnant persons as well as biological testing to evaluate a newborn with possible substance exposure. Standardization is needed to better inform decisions surrounding evaluation of substance exposures in pregnant people and newborns. If biological sampling is pursued, testing options and results must be reviewed in clinical context, acknowledging that false-positive and -negative results can and do occur.
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Affiliation(s)
- Gwendolyn A McMillin
- Department of Pathology and ARUP Laboratories, University of Utah Health, Salt Lake City, UT 84108, United States
| | - Anna W Morad
- Department of Pediatrics, Academic General Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, United States
| | - Jessica M Boyd
- Department of Pathology and ARUP Laboratories, University of Utah Health, Salt Lake City, UT 84108, United States
| | - Kamisha L Johnson-Davis
- Department of Pathology and ARUP Laboratories, University of Utah Health, Salt Lake City, UT 84108, United States
| | - Torri D Metz
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT 84132, United States
| | - Marcela C Smid
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT 84132, United States
| | - Matthew D Krasowski
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, United States
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Dion K, Cardaropoli S, Deshpande R, Kovarik J. Pregnant Women's Experiences of Seeking Treatment for Opioid Use. MCN Am J Matern Child Nurs 2024; 49:225-231. [PMID: 38512125 DOI: 10.1097/nmc.0000000000001024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
PURPOSE The purpose of this study was to describe women's experiences seeking treatment for opioid use disorder during pregnancy. STUDY DESIGN AND METHODS This was an exploratory multi-method study to understand women's experiences seeking treatment for opioid use disorder during pregnancy using surveys and interviews. Women pregnant within the past 5 years while using opioids were recruited from a private Facebook group for mothers on medication for opioid use disorder. Members of this group assisted with the development of the survey. Descriptive statistics were used for the 18-question survey and interviews were recorded, transcribed, and analyzed for themes. RESULTS Twenty-one women completed an online survey, and six participated in an in-depth virtual interview about their experience. Five themes describing their experiences were identified: (1) fear of child protective services, (2) family and partner support, (3) health care providers' reactions, (4) accessing treatment centers, and (5) awareness of support services during pregnancy . CLINICAL IMPLICATIONS Participants reported an overall negative experience seeking treatment for opioid use disorder during pregnancy. Nurses can improve the outcomes for pregnant women with opioid use disorder by using a non-stigmatizing approach, promoting early identification, and providing information, including harm reduction education. Facilitation of resources for treatment, mother and child programs, and advocating for partner treatment can improve maternal and neonatal outcomes.
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Hahn PD, Graham DA, Ozonoff A, Milliren CE. Neonatal Opioid Withdrawal Syndrome Treatment Guidelines and Birth Hospital Utilization. Pediatrics 2024; 154:e2023063635. [PMID: 38899388 DOI: 10.1542/peds.2023-063635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 03/29/2024] [Accepted: 04/01/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND AND OBJECTIVES In November 2020, the American Academy of Pediatrics published guidelines for management of neonatal opioid withdrawal syndrome (NOWS), recommending nonpharmacologic treatment as the first-line approach, unless pharmacologic treatment is needed for severe NOWS. Using data from tertiary care pediatric hospitals, we examined the impact of the guidelines on use of pharmacotherapy, length of stay, and NICU admission for infants with NOWS. METHODS We extracted birth hospitalization data for newborns diagnosed with NOWS discharged from 2019 to 2022 from the Pediatric Health Information System. We compared hospital utilization and pharmacologic treatment pre- and postguidelines and used interrupted time series regression to examine trends over time. RESULTS We included N = 824 newborns (n = 434 pre, n = 390 post) with NOWS from 11 hospitals. The use of pharmacologic treatment was significantly lower in the postguidelines period (59.0% pre versus 50.3% post; P = .01). Median length of stay was similar pre and post (P = .55). NICU admission was significantly lower in the postguidelines period (78.6% pre versus 46.7% post; P < .001), with an immediate decrease (β = -23.0%; P < .001) and a decrease over time in the postguidelines period (β = -0.7% per month; P = .03). Most hospitals reduced pharmacologic treatment (8 of 11; 73%) and NICU use (10 of 11; 91%) postguidelines. CONCLUSIONS There was a reduction in the use of pharmacologic treatment and NICU utilization for infants with NOWS after the release of American Academy of Pediatrics guidelines for NOWS management.
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Affiliation(s)
| | - Dionne A Graham
- Program for Patient Safety and Quality
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Al Ozonoff
- Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Doerzbacher M, Sperlich M, Hequembourg A, Chang YP. A Longitudinal Qualitative Study of Barriers and Facilitators of Breastfeeding in Women on Opioid Maintenance Therapy. J Perinat Neonatal Nurs 2024; 38:306-314. [PMID: 39074327 DOI: 10.1097/jpn.0000000000000847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
Abstract
PURPOSE To understand how barriers and facilitators interact over time to support or disrupt breastfeeding among women on opioid maintenance therapy for opioid use disorder. BACKGROUND Breastfeeding has additional benefits for newborns with prenatal opioid exposure. Up to 80% of women on opioid maintenance therapy plan to breastfeed, but many do not beyond the first 7 to 10 days. METHODS A qualitative, longitudinal design was used. Semi-structured interviews occurred during the third trimester of pregnancy and again between 1 and 6 weeks postpartum. Thematic analysis was conducted using the Breastfeeding in a Life Course Context model as a framework. The design and methods were informed by a post-positivist, critical realist perspective. RESULTS Thirteen participants were enrolled, and 19 interviews were completed. Five themes were identified. It Will Work Out was the primary theme that describes participants' sense of self-efficacy, stemming from their experiences of managing addiction recovery. Women considered breastfeeding to support their own health and that of their newborn while in recovery, summarized by Being Healthy. Making the choice to breastfeed, represented by Weighing the Options, was influenced by their perinatal health care providers. During the Sensitive Period, challenges could overwhelm their self-efficacy. Of 9 women, 4 were still breastfeeding when interviewed postpartum, exemplified by Moving On. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE Participants' self-efficacy and motivation to be healthy played a significant role in managing breastfeeding challenges over time. Nursing interventions must empower women's self-efficacy to help them achieve their breastfeeding goals.
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Affiliation(s)
- Margaret Doerzbacher
- University at Buffalo School of Nursing, Buffalo, New York (Drs Doerzbacher, Hequembourg, and Chang); and University at Buffalo School of Social Work, Buffalo, New York (Dr Sperlich)
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Rohde JF, Chaiyachati BH, Demharter NS, Dorrian C, Gregory EF, Hossain J, McAllister JM, Ratner JA, Schiff DM, Shedlock AR, Sibinga EMS, Goyal NK. Pediatric Primary Care of Children With Intrauterine Opioid Exposure: Survey of Academic Teaching Practices. Acad Pediatr 2024:S1876-2859(24)00217-1. [PMID: 38880392 DOI: 10.1016/j.acap.2024.06.007] [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: 02/23/2024] [Revised: 06/03/2024] [Accepted: 06/06/2024] [Indexed: 06/18/2024]
Abstract
OBJECTIVE Intrauterine opioid exposure (IOE) has increased over the last 2 decades and is associated with additional needs after birth. To date, no clinical guidelines address the primary care of children with IOE. We aimed to characterize clinician-reported screening and referral practices, barriers to effective primary care for children with IOE, and clinician- and practice-level characteristics associated with perceived barriers. METHODS We conducted a cross-sectional survey of pediatric residents, pediatricians, and advanced practitioners at 28 primary care clinics affiliated with 7 pediatric residency programs (April-June 2022). We assessed screening and other clinical practices related to IOE and perceived barriers to addressing parental opioid use disorder (OUD). We used descriptive statistics to analyze survey responses, assessed the distribution of reported barriers, and applied a 2-stage cluster analysis to assess response patterns. RESULTS Of 1004 invited clinicians, 329 (32.8%) responses were returned, and 325 pediatric residents and pediatricians were included in the final analytic sample. Almost all (99.3%) reported parental substance use screening as important, but only 11.6% screened routinely. Half of the respondents routinely refer children with IOE to early intervention services and social work. Lack of standard screening for substance use was the most frequently selected barrier to addressing parental OUD. Participants reporting fewer barriers to addressing parental OUD identified having greater access to OUD treatment programs and home visiting programs. CONCLUSIONS Pediatricians report variations in primary care screenings and referrals for children with IOE. Access to parental OUD treatment programs may mitigate perceived barriers to addressing parental OUD in the pediatric office.
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Affiliation(s)
- Jessica F Rohde
- Division of General Academic Pediatrics (JF Rohde and C Dorrian), Nemours Children's Health, Wilmington, Del; Sidney Kimmel Medical College (JF Rohde, C Dorrian, and NK Goyal), Thomas Jefferson University, Philadelphia, Pa; Value-Based Service Organization (NK Goyal, JF Rohde and C Dorrian), Nemours Children's Health, Philadelphia, Pa.
| | - Barbara H Chaiyachati
- Policy Lab (BH Chaiyachati and EF Gregory), Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics (BH Chaiyachati and EF Gregory), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Neera Shah Demharter
- Penn State Health Children's Hospital (NS Demharter and AR Shedlock), Penn State College of Medicine, Hershey, Pa
| | - Christina Dorrian
- Division of General Academic Pediatrics (JF Rohde and C Dorrian), Nemours Children's Health, Wilmington, Del; Sidney Kimmel Medical College (JF Rohde, C Dorrian, and NK Goyal), Thomas Jefferson University, Philadelphia, Pa; Value-Based Service Organization (NK Goyal, JF Rohde and C Dorrian), Nemours Children's Health, Philadelphia, Pa
| | - Emily F Gregory
- Policy Lab (BH Chaiyachati and EF Gregory), Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics (BH Chaiyachati and EF Gregory), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Jobayer Hossain
- Biostatistics Core (J Hossain), Biomedical Research, Nemours Children's Health, Wilmington, Del
| | - Jennifer M McAllister
- Cincinnati Children's Hospital Perinatal Institute (JM McAllister), University of Cincinnati Department of Pediatrics, Cincinnati, Ohio
| | - Jessica A Ratner
- Division of Addiction Medicine (JA Ratner), Johns Hopkins School of Medicine, Baltimore, Md
| | - Davida M Schiff
- Division of General Academic Pediatrics and Newborn Medicine (DM Schiff), MassGeneral for Children, Boston, Mass
| | - Aaron R Shedlock
- Penn State Health Children's Hospital (NS Demharter and AR Shedlock), Penn State College of Medicine, Hershey, Pa
| | - Erica M S Sibinga
- Department of Pediatrics (EMS Sibinga), Johns Hopkins School of Medicine, Baltimore, Md
| | - Neera K Goyal
- Sidney Kimmel Medical College (JF Rohde, C Dorrian, and NK Goyal), Thomas Jefferson University, Philadelphia, Pa; Value-Based Service Organization (NK Goyal, JF Rohde and C Dorrian), Nemours Children's Health, Philadelphia, Pa
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11
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Everett SS, Bomback M, Roth P, Goldshtrom N, Polin RA, Lyford A, Hays T. Nine is the New Ten of Apgar Scores: An Observational Retrospective Cohort Study. J Pediatr 2024; 273:114150. [PMID: 38880381 DOI: 10.1016/j.jpeds.2024.114150] [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: 03/11/2024] [Revised: 04/29/2024] [Accepted: 06/11/2024] [Indexed: 06/18/2024]
Abstract
Apgar scores of 10 were once common but are now rare. We aggregated scores from US term infants from 1978 to 2021. We found that scores of 10 decreased by logarithmic decay independent of demographic changes. We hypothesize that this trend was driven by improved appreciation of transitional physiology.
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Affiliation(s)
- Selin S Everett
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Washington Medical Center, Seattle, WA
| | - Miles Bomback
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | - Nimrod Goldshtrom
- Division of Neonatology, Department of Pediatrics, Columbia University Irving Medical Center, New York City, NY
| | - Richard A Polin
- Division of Neonatology, Department of Pediatrics, Columbia University Irving Medical Center, New York City, NY
| | - Alex Lyford
- Department of Statistics, Middlebury College, Middlebury, VT
| | - Thomas Hays
- Division of Neonatology, Department of Pediatrics, Columbia University Irving Medical Center, New York City, NY.
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12
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Devlin LA, Hu Z, Merhar SL, Ounpraseuth ST, Simon AE, Lee JY, Das A, Crawford MM, Greenberg RG, Smith PB, Higgins RD, Walsh MC, Rice W, Paul DA, Maxwell JR, Fung CM, Wright T, Ross J, McAllister JM, Crowley M, Shaikh SK, Christ L, Brown J, Riccio J, Wong Ramsey K, Braswell EF, Tucker L, McAlmon K, Dummula K, Weiner J, White JR, Newman S, Snowden JN, Young LW. Influence of Eat, Sleep, and Console on Infants Pharmacologically Treated for Opioid Withdrawal: A Post Hoc Subgroup Analysis of the ESC-NOW Randomized Clinical Trial. JAMA Pediatr 2024; 178:525-532. [PMID: 38619854 PMCID: PMC11019446 DOI: 10.1001/jamapediatrics.2024.0544] [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] [Received: 12/04/2023] [Accepted: 01/24/2024] [Indexed: 04/16/2024]
Abstract
Importance The function-based eat, sleep, console (ESC) care approach substantially reduces the proportion of infants who receive pharmacologic treatment for neonatal opioid withdrawal syndrome (NOWS). This reduction has led to concerns for increased postnatal opioid exposure in infants who receive pharmacologic treatment. However, the effect of the ESC care approach on hospital outcomes for infants pharmacologically treated for NOWS is currently unknown. Objective To evaluate differences in opioid exposure and total length of hospital stay (LOS) for pharmacologically treated infants managed with the ESC care approach vs usual care with the Finnegan tool. Design, Setting, and Participants This post hoc subgroup analysis involved infants pharmacologically treated in ESC-NOW, a stepped-wedge cluster randomized clinical trial conducted at 26 US hospitals. Hospitals maintained pretrial practices for pharmacologic treatment, including opioid type, scheduled opioid dosing, and use of adjuvant medications. Infants were born at 36 weeks' gestation or later, had evidence of antenatal opioid exposure, and received opioid treatment for NOWS between September 2020 and March 2022. Data were analyzed from November 2022 to January 2024. Exposure Opioid treatment for NOWS and the ESC care approach. Main Outcomes and Measures For each outcome (total opioid exposure, peak opioid dose, time from birth to initiation of first opioid dose, length of opioid treatment, and LOS), we used generalized linear mixed models to adjust for the stepped-wedge design and maternal and infant characteristics. Results In the ESC-NOW trial, 463 of 1305 infants were pharmacologically treated (143/603 [23.7%] in the ESC care approach group and 320/702 [45.6%] in the usual care group). Mean total opioid exposure was lower in the ESC care approach group with an absolute difference of 4.1 morphine milligram equivalents per kilogram (MME/kg) (95% CI, 1.3-7.0) when compared with usual care (4.8 MME/kg vs 8.9 MME/kg, respectively; P = .001). Mean time from birth to initiation of pharmacologic treatment was 22.4 hours (95% CI, 7.1-37.7) longer with the ESC care approach vs usual care (75.4 vs 53.0 hours, respectively; P = .002). No significant difference in mean peak opioid dose was observed between groups (ESC care approach, 0.147 MME/kg, vs usual care, 0.126 MME/kg). The mean length of treatment was 6.3 days shorter (95% CI, 3.0-9.6) in the ESC care approach group vs usual care group (11.8 vs 18.1 days, respectively; P < .001), and mean LOS was 6.2 days shorter (95% CI, 3.0-9.4) with the ESC care approach than with usual care (16.7 vs 22.9 days, respectively; P < .001). Conclusion and Relevance When compared with usual care, the ESC care approach was associated with less opioid exposure and shorter LOS for infants pharmacologically treated for NOWS. The ESC care approach was not associated with a higher peak opioid dose, although pharmacologic treatment was typically initiated later. Trial Registration ClinicalTrials.gov Identifier: NCT04057820.
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Affiliation(s)
- Lori A Devlin
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky
| | - Zhuopei Hu
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock
| | - Stephanie L Merhar
- University of Cincinnati College of Medicine and Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Alan E Simon
- IDeA States Pediatric Clinical Trials Network (ISPCTN), Environmental Influences on Child Health Outcomes (ECHO) Program, National Institutes of Health, Rockville, Maryland
- National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland
| | - Jeannette Y Lee
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock
| | - Abhik Das
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | - Margaret M Crawford
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | - Rachel G Greenberg
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - P Brian Smith
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Rosemary D Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
- Office of Research and Sponsored Programs, Florida Gulf Coast University, Fort Myers
| | - Michele C Walsh
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Ward Rice
- University of Cincinnati College of Medicine and Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- St Elizabeth Healthcare, Edgewood, Kentucky
| | - David A Paul
- Division of Neonatology, Department of Pediatrics, ChristianaCare, Newark, Delaware
| | | | - Camille M Fung
- Department of Pediatrics, Division of Neonatology, University of Utah School of Medicine, Salt Lake City
| | - Tanner Wright
- Department of Pediatrics, University of South Florida, Tampa
| | - Julie Ross
- Medical University of South Carolina, Health Shawn Jenkins Children's Hospital, Charleston
| | - Jennifer M McAllister
- University of Cincinnati College of Medicine and Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Moira Crowley
- Department of Pediatrics, Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Sophie K Shaikh
- Department of Pediatrics, Duke University, Durham, North Carolina
| | - Lori Christ
- Hospital of the University of Pennsylvania, Philadelphia
| | - Jaime Brown
- Department of Pediatrics, Spartanburg Regional Medical Center, Spartanburg, South Carolina
| | - Julie Riccio
- University of Rochester School of Medicine and Dentistry, Rochester, New York
| | | | - Erica F Braswell
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus
| | - Lauren Tucker
- Department of Pediatrics, University of Mississippi Medical Center, Jackson
| | | | - Krishna Dummula
- Department of Pediatrics, University of Kansas Medical Center, Kansas City, Missouri
| | - Julie Weiner
- Children's Mercy Hospital, Kansas City, Missouri
| | | | | | - Jessica N Snowden
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock
| | - Leslie W Young
- Larner College of Medicine at the University of Vermont, Burlington
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Jalali A. Informing evidence-based medicine for opioid use disorder using pharmacoeconomic studies. Expert Rev Pharmacoecon Outcomes Res 2024; 24:599-611. [PMID: 38696161 DOI: 10.1080/14737167.2024.2350561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 04/29/2024] [Indexed: 05/08/2024]
Abstract
INTRODUCTION The health and economic consequences of inadequately treated opioid use disorder (OUD) are substantial. Healthcare systems in the United States (US) and other countries are facing a growing healthcare crisis due to opioids. Although effective medications for OUD exist, relying solely on clinical information is insufficient for addressing the opioid crisis. AREAS COVERED In this review, the role of pharmacoeconomic studies in informing evidence-based medication treatment for OUD is discussed, with a particular emphasis on the US healthcare system, where the economic burden is significantly higher than the global average. The scope/objective of pharmacoeconomics as a distinct scientific research program is briefly defined, followed by a discussion of existing evidence informed by data from systematic reviews, in addition to a convenience sample of recently published pharmacoeconomic studies and protocols. The review also explores the need for methodological advancements in the field. EXPERT OPINION Despite the potential of pharmacoeconomic research in shaping evidence-based medicine for OUD, significant challenges limiting its real-world application remain. How to address these challenges are explored, including how to combine cost-effectiveness and budget impact analyses to address the needs of the healthcare system as a whole and specific stakeholders interested in adopting new OUD treatment strategies.
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Affiliation(s)
- Ali Jalali
- Department of Population Health Sciences, Division of Comparative Effectiveness & Outcomes Research, Joan and Sanford I. Weill Medical College of Cornell University, New York, NY, USA
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Wiese AD, Phillippi JC, Muhar A, Polic A, Liu G, Loch SF, Ong HH, Su WC, Leech AA, Reese T, Wei WQ, Patrick SW. Performance of Phenotype Algorithms for the Identification of Opioid-Exposed Infants. Hosp Pediatr 2024; 14:438-447. [PMID: 38804051 PMCID: PMC11137624 DOI: 10.1542/hpeds.2023-007546] [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: 08/31/2023] [Revised: 01/23/2024] [Accepted: 02/03/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVE Observational studies examining outcomes among opioid-exposed infants are limited by phenotype algorithms that may under identify opioid-exposed infants without neonatal opioid withdrawal syndrome (NOWS). We developed and validated the performance of different phenotype algorithms to identify opioid-exposed infants using electronic health record data. METHODS We developed phenotype algorithms for the identification of opioid-exposed infants among a population of birthing person-infant dyads from an academic health care system (2010-2022). We derived phenotype algorithms from combinations of 6 unique indicators of in utero opioid exposure, including those from the infant record (NOWS or opioid-exposure diagnosis, positive toxicology) and birthing person record (opioid use disorder diagnosis, opioid drug exposure record, opioid listed on medication reconciliation, positive toxicology). We determined the positive predictive value (PPV) and 95% confidence interval for each phenotype algorithm using medical record review as the gold standard. RESULTS Among 41 047 dyads meeting exclusion criteria, we identified 1558 infants (3.80%) with evidence of at least 1 indicator for opioid exposure and 32 (0.08%) meeting all 6 indicators of the phenotype algorithm. Among the sample of dyads randomly selected for review (n = 600), the PPV for the phenotype requiring only a single indicator was 95.4% (confidence interval: 93.3-96.8) with varying PPVs for the other phenotype algorithms derived from a combination of infant and birthing person indicators (PPV range: 95.4-100.0). CONCLUSIONS Opioid-exposed infants can be accurately identified using electronic health record data. Our publicly available phenotype algorithms can be used to conduct research examining outcomes among opioid-exposed infants with and without NOWS.
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Affiliation(s)
- Andrew D. Wiese
- Departments of Health Policy
- Vanderbilt Center for Child Health Policy
| | - Julia C. Phillippi
- Vanderbilt Center for Child Health Policy
- School of Nursing, Vanderbilt University, Nashville, Tennessee
| | | | | | - Ge Liu
- Center for Precision Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Henry H. Ong
- Center for Precision Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Wu-Chen Su
- Center for Precision Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ashley A. Leech
- Departments of Health Policy
- Vanderbilt Center for Child Health Policy
| | | | - Wei-Qi Wei
- Center for Precision Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephen W. Patrick
- Departments of Health Policy
- Pediatrics
- Vanderbilt Center for Child Health Policy
- Mildred Stahlman Division of Neonatology
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Robinson TW, Stikes R, Sorrell J, Gater A, Booth AT, Gardner A, Greenwell C, Businger S, Low R, Petrie R. Treatment for Neonatal Abstinence Syndrome using Nonpharmacological Interventions. Am J Perinatol 2024. [PMID: 38729163 DOI: 10.1055/s-0044-1786744] [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] [Indexed: 05/12/2024]
Abstract
OBJECTIVE Management of neonatal abstinence syndrome includes nonpharmacological interventions, but their effectiveness may not be verified before implemented. The objective of this study is to evaluate the effectiveness of a type of bassinet in the treatment of infants with neonatal abstinence syndrome. STUDY DESIGN This is a retrospective observational cohort study. Study setting involved a 24-bed open-bay Level III neonatal intensive care unit located in a metropolitan academic trauma facility. Participant inclusion criteria involved prenatally opioid-exposed infants ≥ 35 weeks with confirmed maternal opioid urine toxicology, required pharmacological treatment for withdrawal symptoms, and were admitted to the neonatal intensive care unit. Three subsets of study participants were analyzed over three different time periods: Group 1 were infants admitted during 2019 without nonpharmacological intervention, Group 2 who were admitted from September 2021 to February 2022 and received nonpharmacological interventions, and Group 3 included those admitted from February 2022 to March 2023 who received the same interventions as Group 2 but were managed in bassinets being used in other local facilities for neonatal abstinence syndrome. RESULTS Group 3 had significant increases in length of stay compared with Group 1 (p = 0.006) and Group 2 (p = 0.013). Group 3 had a significantly greater length of treatment than Group 1 (p = 0.041) and a significantly higher total mg/kg morphine exposure than Group 1 (p = 0.006). CONCLUSION Addition of the bassinet for nonpharmacological management of infants with neonatal abstinence syndrome appeared to prolong length of stay, length of treatment, and increase total mg/kg morphine exposure. As a retrospective nonrandomized study, weakness of low certainty of causality is of concern but findings strongly warrant further research before devices such as the bassinet used in this study are adopted for routine neonatal abstinence syndrome care. KEY POINTS · Special bassinets are promoted to enhance sleep and decrease agitation.. · Such bassinets may assist infants undergoing drug withdrawal.. · Study of the bassinet failed to show benefit to this population..
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Affiliation(s)
- Tonya W Robinson
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky
| | - Reetta Stikes
- Center for Women and Infants, University of Louisville Hospital, Louisville, Kentucky
| | - Jaki Sorrell
- Center for Women and Infants, University of Louisville Hospital, Louisville, Kentucky
| | - Amanda Gater
- Center for Women and Infants, University of Louisville Hospital, Louisville, Kentucky
| | - Adam T Booth
- Center for Women and Infants, University of Louisville Hospital, Louisville, Kentucky
| | - Amanda Gardner
- Center for Women and Infants, University of Louisville Hospital, Louisville, Kentucky
| | - Colleen Greenwell
- Center for Women and Infants, University of Louisville Hospital, Louisville, Kentucky
| | - Shannon Businger
- Center for Women and Infants, University of Louisville Hospital, Louisville, Kentucky
| | - Ryan Low
- Center for Women and Infants, University of Louisville Hospital, Louisville, Kentucky
| | - Rachael Petrie
- Center for Women and Infants, University of Louisville Hospital, Louisville, Kentucky
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Jilani SM, Davis JM, Goldstein D, Grossman M, Jansson LM, Terplan M, Jones HE. Clinically defining the opioid-exposed birthing person and infant as a dyad to support bedside care, surveillance, and research. Front Pediatr 2024; 12:1349102. [PMID: 38774300 PMCID: PMC11106404 DOI: 10.3389/fped.2024.1349102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 04/19/2024] [Indexed: 05/24/2024] Open
Abstract
Introduction An increased incidence of maternal opioid use disorder (OUD) and neonatal abstinence syndrome (NAS) has prompted recommendations supporting a dyadic approach to care for birthing persons and their infants. However, there are no consensus guidelines outlining how the dyad is clinically defined. Methods To examine how the opioid-exposed birthing person-infant dyad has been defined for purposes of data collection and research, a literature review applying the RAND/UCLA Appropriateness Method was conducted. Results The search yielded 320 abstracts, with 110 articles identified as having a dyadic focus. While no articles included a specific definition for the dyad, 33 (30%) contained a descriptive reference to the birthing person-infant dyad. Thematic analysis revealed eight recurring elements characteristic of the dyad: (1) engagement, (2) communication, (3) bonding, (4) attachment, (5) mutual responsiveness, (6) reciprocity, (7) synchrony, and (8) attunement. Integrating these elements revealed the interactional relationship between the opioid-exposed birthing person and infant as the foundational principle that defines the dyad. Discussion This definition shifts the focus of the opioid-exposed dyad from two individual patient populations to an interactional relationship that has broad applicability for clinical use, public health data collection, and research considerations.
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Affiliation(s)
- Shahla M. Jilani
- Office of the Assistant Secretary for Health, U.S. Department of Health and Human Services, Washington, DC, United States
| | - Jonathan M. Davis
- Division of Newborn Medicine, Tufts Medical Center, Boston, MA, United States
- The Tufts Clinical and Translational Science Institute, Boston, MA, United States
| | - David Goldstein
- Office of the Assistant Secretary for Health, U.S. Department of Health and Human Services, Washington, DC, United States
| | - Matthew Grossman
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, United States
| | - Lauren M. Jansson
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Center for Addiction and Pregnancy, Baltimore, MD, United States
| | - Mishka Terplan
- Friends Research Institute, Baltimore, MD, United States
| | - Hendrée E. Jones
- Department of Obstetrics and Gynecology, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Psychiatry & Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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17
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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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Gissandaner TD, Wen A, Gette JA, Perry KJ, Mutignani LM, Regan T, Malloch L, Tucker LC, White CB, Fry TB, Lim CS, Annett RD. Considerations and Determinants of Discharge Decisions among Prenatal Substance Exposed Infants. CHILD MALTREATMENT 2024; 29:246-258. [PMID: 36917045 PMCID: PMC10500030 DOI: 10.1177/10775595231161996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Limited research has examined a comprehensive set of predictors when evaluating discharge placement decisions for infants exposed to substances prenatally. Using a previously validated medical record data extraction tool, the current study examined prenatal substance exposure, infant intervention (i.e., pharmacologic, or non-pharmacologic), and demographic factors (e.g., race and ethnicity and rurality) as predictors of associations with discharge placement in a sample from a resource-poor state (N = 136; 69.9% Non-Hispanic White). Latent class analysis (LCA) was used to examine whether different classes emerged and how classes were differentially related to discharge placement decisions. Logistic regressions were used to determine whether each predictor was uniquely associated with placement decisions. Results of the LCA yielded a two-class solution comprised of (1) a Low Withdrawal Risk class, characterized by prenatal exposure to substances with low risk for neonatal abstinence syndrome (NAS) and non-pharmacologic intervention, and (2) a High Withdrawal Risk class, characterized by a high risk of NAS and pharmacologic intervention. Classes were not related to discharge placement decisions. Logistic regressions demonstrated that meth/amphetamine use during pregnancy was associated with greater odds of out of home placement above other substance types. Future research should replicate and continue examining the clinical utility of these classes.
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Affiliation(s)
- Tre D. Gissandaner
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA
| | - Alainna Wen
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jordan A. Gette
- Center of Alcohol and Substance Use Studies, Rutgers, the State University of New Jersey, New Brunswick, NJ, USA
| | - Kristin J. Perry
- Edna Bennett Pierce Prevention Research Center, Pennsylvania State University, University Park, PA, USA
| | - Lauren M. Mutignani
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA
| | - Timothy Regan
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lacy Malloch
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, USA
| | - Lauren C. Tucker
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, USA
| | | | - Taylor B. Fry
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, USA
| | - Crystal S. Lim
- Department of Health Psychology, University of Missouri, Columbia, MO, USA
| | - Robert D. Annett
- University of New Mexico Health Sciences Center, Albuquerque, NM, USA
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Pratt-Chavez H, Rishel Brakey H, Sanders SG, Patel J, Ozechowski T, Stoffel C, Sussman AL, Marquez J, Smith DR, Kong AS. Evaluating a web-based training curriculum for disseminating best practices for the care of newborns with neonatal opioid withdrawal syndrome in a rural hospital, the NOWS-NM Program. BMC Pediatr 2024; 24:258. [PMID: 38641785 PMCID: PMC11027285 DOI: 10.1186/s12887-024-04710-5] [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: 01/30/2023] [Accepted: 03/13/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND The incidence of neonatal opiate withdrawal syndrome (NOWS) in the US has grown dramatically over the past two decades. Many rural hospitals not equipped to manage these patients transfer them to hospitals in bigger cities. METHODS We created a curriculum, the NOWS-NM Program, a web-based curriculum training in best practices. To evaluate the curriculum, we conducted pre- and post-surveys of NOWS knowledge, attitudes, and care practices, plus post-curriculum interviews and focus groups. RESULTS Fourteen participants completed both pre- and post-curriculum surveys. They indicated an increase in knowledge and care practices. A small number of respondents expressed negative attitudes about parents of infants with NOWS at pre-test, the training curriculum appeared to have no impact on such attitudes at post-test. Sixteen participants participated in focus groups or interviews. Qualitative data reinforced the positive quantitative results and contradicted the negative survey results, respondents reported that the program did reduce stigma and improve provider/staff interactions with patients. CONCLUSIONS This curriculum demonstrated positive impacts on NOWS knowledge and care practices. Incorporating focus on core concepts of trauma-informed care and self-regulation in future iterations of the curriculum may strengthen the opportunity to change attitudes and address the needs expressed by participants and improve care of families and babies with NOWS.
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Affiliation(s)
- Heather Pratt-Chavez
- School of Medicine, Department of Pediatrics, University of New Mexico, MSC10 5590, Albuquerque, NM, 87131, USA.
| | - Heidi Rishel Brakey
- Clinical & Translational Science Center, University of New Mexico, MSC08 4635, Albuquerque, NM, 87131, USA
| | - Sarah G Sanders
- School of Medicine, Department of Pediatrics, University of New Mexico, MSC10 5590, Albuquerque, NM, 87131, USA
| | - Juhee Patel
- University of New Mexico School of Medicine, University of New Mexico, MSC08 4560, Albuquerque, NM, 87131, USA
| | - Tim Ozechowski
- School of Medicine, Department of Pediatrics, University of New Mexico, MSC10 5590, Albuquerque, NM, 87131, USA
| | - Chloe Stoffel
- School of Medicine, Department of Pediatrics, University of New Mexico, MSC10 5590, Albuquerque, NM, 87131, USA
| | - Andrew L Sussman
- Department of Family and Community Medicine and the Comprehensive Cancer Center, University of New Mexico, MSC 09 5040, Albuquerque, NM, 87131, USA
| | - Jessie Marquez
- Influents Innovations, 3800 Sports Way, Springfield, OR, 97477, USA
| | - David R Smith
- Influents Innovations, 3800 Sports Way, Springfield, OR, 97477, USA
| | - Alberta S Kong
- School of Medicine, Department of Pediatrics, University of New Mexico, MSC10 5590, Albuquerque, NM, 87131, USA
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Dempsey S, O' Grady MJ. Current management of neonatal abstinence syndrome: a survey of practice in the UK and Ireland. Arch Dis Child Fetal Neonatal Ed 2024; 109:261-264. [PMID: 37879885 DOI: 10.1136/archdischild-2023-326204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 10/11/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVE To study the current management practices of neonatal abstinence syndrome (NAS) throughout the UK and Ireland and identify changes in practice from the most recent survey in 2008. DESIGN Postal questionnaire to a consultant paediatrician or neonatologist in all 215 neonatal units in the UK and Ireland in January 2020. RESULTS Response rate was 62%. An objective scoring tool was used in 97% of units and the Finnegan score was favoured by 70%. Morphine sulfate use as first line for the treatment of opiate withdrawal was almost universal and 70% used a dose of 40 µg/kg every 4 hours (240 µg/kg/day). Phenobarbitone administration as a second-line agent for opiate withdrawal increased to 61% of units with significant reductions in chloral hydrate and chlorpromazine use compared with the previous survey. Morphine sulfate and phenobarbitone remain the preferred first-line and second-line agents, respectively, for polysubstance withdrawal. There was a significant increase in chlorpromazine use as first line for polydrug withdrawal (1.5-14.2%). The practice of units discharging infants' home on medication increased to 46% from 29%. All units now permit breastfeeding in mothers taking methadone, compared with 81% previously. CONCLUSION AND RELEVANCE Compared with the previous survey, improvements in evidence-based practices were noted, highlighting the benefits of this type of research. Nonetheless, significant variation still exists in some aspects of the management of NAS. Post-discharge follow-up varies widely, with particular deficits in ophthalmology follow-up.
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Affiliation(s)
- Sharon Dempsey
- Department of Paediatrics, Regional Hospital Mullingar, Mullingar, Westmeath, Ireland
| | - Michael J O' Grady
- Department of Paediatrics, Regional Hospital Mullingar, Mullingar, Westmeath, Ireland
- Women's and Children's Health, University College Dublin, Dublin, Ireland
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Schwartz AN, Meschke LL. An epidemiological examination of neonatal opioid withdrawal syndrome and maternal and infant characteristics. Arch Womens Ment Health 2024:10.1007/s00737-024-01460-2. [PMID: 38573341 DOI: 10.1007/s00737-024-01460-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 03/23/2024] [Indexed: 04/05/2024]
Abstract
PURPOSE Analyze maternal and infant characteristics by Neonatal Opioid Withdrawal Syndrome (NOWS) status and examine the association between mothers with Hepatitis C Virus (HCV) and infants diagnosed with NOWS. METHODS Hospital discharge diagnoses of low-income women in Tennessee were used to identify NOWS cases (n = 1,369) in 2013 and 2014 and randomly selected controls (n = 1,369) were matched on county of residence and birth year. Maternal and infant characteristics were obtained by linking these data to birth certificate data. RESULTS Of Tennessee's 683 cases of NOWS in 2013 and 686 in 2014, most (69%) occurred in Eastern Tennessee. Mothers of infants with NOWS were more likely to be older, unmarried, and white than mothers of infants without NOWS. Mothers of infants with NOWS also faced greater health risk: more smoking, HCV, herpes simplex diagnosis, and no or less frequent prenatal care (p < .0001). Infants with NOWS were more likely to present with infection, be admitted into the NICU, have lower birth weight, be enrolled in TennCare, but less likely to be breastfed than infants without NOWS (p < .0001). After adjusting for demographic factors and smoking, compared to mothers of infants without NOWS, mothers of infants with NOWS had an alarmingly increased odds of HCV [OR = 12.97 (95% CI 7.42, 22.66)]. CONCLUSIONS This study emphasizes the complexity of challenges facing families impacted by NOWS, the importance of multifaceted prevention, and the need to conduct HCV testing in NOWS infants.
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Affiliation(s)
- Ashlyn N Schwartz
- Department of Public Health and Primary Care, Trinity College Dublin, Tallaght Cross West Tallaght, Dublin, D24 DH74, Ireland.
- Bordeaux Population Health Research Center, U1219, University of Bordeaux, Bordeaux, France.
| | - Laurie L Meschke
- Department of Public Health, University of Tennessee-Knoxville, Knoxville, USA
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McGrath SV, Rivera A, Kennie-Richardson C, Ehrmann D, Cline J, Gable K, Forrest V. Evaluating the Impact of Eat, Sleep, Console in Neonatal Abstinence Syndrome Treatment for Infants Exposed to Substance Use In Utero. J Pediatr Pharmacol Ther 2024; 29:151-158. [PMID: 38596426 PMCID: PMC11001210 DOI: 10.5863/1551-6776-29.2.151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 07/23/2023] [Indexed: 04/11/2024]
Abstract
OBJECTIVE An increase in maternal use of licit or illicit substances, alcohol, and tobacco has resulted in an increased incidence of neonatal abstinence syndrome (NAS). In recent years, NAS management has shifted to initiating an Eat, Sleep, Console (ESC) approach prior to pharmacologic treatment. The objective of this study was to evaluate the impact of ESC in combination with pharmacologic treatment in the management of NAS for infants exposed to substance use in utero. METHODS This single system, multisite, retrospective cohort study evaluated infants with known exposure to substance or polysubstance use in utero or those who had signs and symptoms of withdrawal with a positive toxicology screen. The primary outcome of rate of pharmacologic therapy initiated was evaluated pre and post implementation of ESC. Secondary outcomes included hospital length of stay, day of life that pharmacologic therapy was initiated, and an evaluation of the ESC guideline. A subgroup analysis with similar outcomes was also performed for patients with maternal polysubstance use. RESULTS A total of 2843 patients were screened, and 50 patients were randomly selected for -inclusion in both pre- and post-groups. The rate of pharmacologic therapy initiated post implementation of ESC decreased from 58% to 30% (p < 0.01). In the post-group, there was a decrease in the number of -patients requiring scheduled morphine (33%, p < 0.01) and duration of pharmacologic therapy (14.6 days vs 6.47 days, p < 0.01). CONCLUSIONS Implementing an ESC guideline decreased the length of stay and rate of pharmacologic intervention needed for infants with NAS at our institution.
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Affiliation(s)
- Shannon V McGrath
- Department of Pharmacy (SVM, JC, CK-R, AR, VF), Cone Health Women's and Children's Center, Greensboro, NC
| | - Allie Rivera
- Department of Pharmacy (SVM, JC, CK-R, AR, VF), Cone Health Women's and Children's Center, Greensboro, NC
| | | | - David Ehrmann
- Department of Neonatology (DE, KG), Cone Health Women's and Children's Center, Greensboro, NC
- Neonatology (DE), Cone Health Alamance Regional Medical Center, Burlington, NC
| | - Julie Cline
- Department of Pharmacy (SVM, JC, CK-R, AR, VF), Cone Health Women's and Children's Center, Greensboro, NC
| | - Kaye Gable
- Department of Neonatology (DE, KG), Cone Health Women's and Children's Center, Greensboro, NC
| | - Victoria Forrest
- Department of Pharmacy (SVM, JC, CK-R, AR, VF), Cone Health Women's and Children's Center, Greensboro, NC
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Narbey L, Cline A, Demirci JR. Lactation Support for Birthing People With Perinatal Opioid Use Disorder. J Perinat Neonatal Nurs 2024; 38:131-134. [PMID: 38758268 DOI: 10.1097/jpn.0000000000000818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
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Madurai NK, Jantzie LL, Yen E. Sex differences in neonatal outcomes following prenatal opioid exposure. Front Pediatr 2024; 12:1357970. [PMID: 38577634 PMCID: PMC10991792 DOI: 10.3389/fped.2024.1357970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 03/04/2024] [Indexed: 04/06/2024] Open
Abstract
The impact of the opioid epidemic on pregnant people and children is a growing public health crisis. Understanding how opioids affect the developing brain during pregnancy and postnatally remains a critical area of investigation. Biological sex plays a crucial role in all physiologic processes, with the potential for a significant impact on neonatal outcomes, including those infants with opioid exposure. Here, we aim to explore current literature on the effect of sex on neonatal outcomes following prenatal opioid exposure. Sex differences in adults with opioid use disorder have been well studied, including increased mortality among males and higher rates of psychiatric comorbidities and likelihood of relapse in females. However, such differences are not yet well understood in neonates. Emerging clinical data suggest sex-specific effects in infants with prenatal opioid exposure on the expression of genes related to feeding regulation and reward signaling pathways. Increased susceptibility to white matter injury has also been noted in female infants following prenatal opioid exposure. Understanding the impact of sex as a biological variable on neonatal outcomes following prenatal opioid exposure is paramount to improving the health and well-being of infants, children, and adults impacted by the opioid epidemic.
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Affiliation(s)
- Nethra K. Madurai
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Lauren L. Jantzie
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- 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
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Elizabeth Yen
- Mother Infant Research Institute (MIRI), Tufts Medical Center, Boston, MA, United States
- Division of Newborn Medicine, Tufts Medicine Pediatrics-Boston Children's, Boston, MA, United States
- Department of Pediatrics, Tufts University School of Medicine, Boston, MA, United States
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van Hoogdalem MW, Tanaka R, Abduljalil K, Johnson TN, Wexelblatt SL, Akinbi HT, Vinks AA, Mizuno T. Forecasting Fetal Buprenorphine Exposure through Maternal-Fetal Physiologically Based Pharmacokinetic Modeling. Pharmaceutics 2024; 16:375. [PMID: 38543269 PMCID: PMC10975492 DOI: 10.3390/pharmaceutics16030375] [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: 02/13/2024] [Revised: 03/02/2024] [Accepted: 03/06/2024] [Indexed: 04/01/2024] Open
Abstract
Buprenorphine readily crosses the placenta, and with greater prenatal exposure, neonatal opioid withdrawal syndrome (NOWS) likely grows more severe. Current dosing strategies can be further improved by tailoring doses to expected NOWS severity. To allow the conceptualization of fetal buprenorphine exposure, a maternal-fetal physiologically based pharmacokinetic (PBPK) model for sublingual buprenorphine was developed using Simcyp (v21.0). Buprenorphine transplacental passage was predicted from its physicochemical properties. The maternal-fetal PBPK model integrated reduced transmucosal absorption driven by lower salivary pH and induced metabolism observed during pregnancy. Maternal pharmacokinetics was adequately predicted in the second trimester, third trimester, and postpartum period, with the simulated area under the curve from 0 to 12 h, apparent clearance, and peak concentration falling within the 1.25-fold prediction error range. Following post hoc adjustment of the likely degree of individual maternal sublingual absorption, umbilical cord blood concentrations at delivery (n = 21) were adequately predicted, with a geometric mean ratio between predicted and observed fetal concentrations of 1.15 and with 95.2% falling within the 2-fold prediction error range. The maternal-fetal PBPK model developed in this study can be used to forecast fetal buprenorphine exposure and would be valuable to investigate its correlation to NOWS severity.
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Affiliation(s)
- Matthijs W. van Hoogdalem
- Division of Translational and Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA; (M.W.v.H.); (R.T.); (A.A.V.)
- James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH 45229, USA
| | - Ryota Tanaka
- Division of Translational and Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA; (M.W.v.H.); (R.T.); (A.A.V.)
| | - Khaled Abduljalil
- Certara UK Limited, Simcyp Division, Sheffield S1 2BJ, UK; (K.A.); (T.N.J.)
| | - Trevor N. Johnson
- Certara UK Limited, Simcyp Division, Sheffield S1 2BJ, UK; (K.A.); (T.N.J.)
| | - Scott L. Wexelblatt
- Division of Neonatology, Perinatal Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA; (S.L.W.); (H.T.A.)
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
- Center for Addiction Research, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Henry T. Akinbi
- Division of Neonatology, Perinatal Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA; (S.L.W.); (H.T.A.)
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Alexander A. Vinks
- Division of Translational and Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA; (M.W.v.H.); (R.T.); (A.A.V.)
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
- Center for Addiction Research, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Tomoyuki Mizuno
- Division of Translational and Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA; (M.W.v.H.); (R.T.); (A.A.V.)
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
- Center for Addiction Research, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
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Hadland SE, Schiff DM. Opioids in Hospitalized Infants-Managing Pain and Sedation While Avoiding Overuse. JAMA Netw Open 2024; 7:e240523. [PMID: 38470425 PMCID: PMC11138138 DOI: 10.1001/jamanetworkopen.2024.0523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/13/2024] Open
Affiliation(s)
- Scott E. Hadland
- Division of Adolescent and Young Adult Medicine, Mass General for Children / Harvard Medical School, Boston, MA
| | - Davida M. Schiff
- Divisions of General Academic Pediatrics and Newborn Medicine, Mass General for Children / Harvard Medical School, Boston, MA
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Jilani SM, Davis JM, Grossman M, Jones HE, Terplan M, Jansson LM. A Dyadic Framework of Care for Opioid-exposed Birthing Persons and Their Infants and Children. J Pediatr 2024; 266:113893. [PMID: 38142930 DOI: 10.1016/j.jpeds.2023.113893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 12/07/2023] [Accepted: 12/18/2023] [Indexed: 12/26/2023]
Abstract
OBJECTIVE To develop a dyadic-centered framework focused on clinical care, surveillance, and research for birthing persons with opioid use disorder (OUD) and their infants and children. STUDY DESIGN Between February and March 2023, an analysis was conducted within the US Department of Health and Human Services (HHS) of activities directed at opioid-exposed birthing persons and their infants and children (the dyad) to identify: 1) number of activities, stratified by type and 2) characteristics across health and supportive activities that serve the dyad vs birthing persons or infants and children individually. Descriptive and thematic analyses were used to assess quantity and characteristics of fiscal year 2023-2024 activities aggregated across eleven HHS agencies. RESULTS Of 181 activities examined, 75 met inclusion criteria specific to serving birthing persons with OUD and opioid-exposed infants and children. Sixty-two percent of activities were dyad focused. Five categories of dyadic activities were identified: research (45%), education and training (28%), health and supportive services (21%), surveillance (4%), and quality improvement (2%). Eight specific characteristics were key to dyadic activities: a life course and generational approach, emphasis on relationship, dyadic outcomes, service wraparound, payment structures supporting dyadic care, data linkage, and social determinants of health. CONCLUSIONS This analysis of HHS activities directed at birthing persons with OUD and opioid-exposed infants and children showed that most programs had a dyadic focus. Synthesizing elements identified from activities serving the dyad facilitated the development of a dyadic framework integrating clinical care, public health surveillance, and research.
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Affiliation(s)
- Shahla M Jilani
- Office of the Assistant Secretary for Health, U.S. Department of Health and Human Services, Washington, DC.
| | - Jonathan M Davis
- Division of Newborn Medicine, Tufts Medical Center, Boston, MA and The Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA
| | - Matthew Grossman
- Department of Pediatrics, Yale School of Medicine, New Haven, CT
| | - Hendrée E Jones
- Department of Obstetrics and Gynecology, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Lauren M Jansson
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
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Cleveland LM, McGlothen-Bell K. Drug Testing of Pregnant Patients. J Obstet Gynecol Neonatal Nurs 2024; 53:93-95. [PMID: 38331389 DOI: 10.1016/j.jogn.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024] Open
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Goss T, Esguerra J, Newman C, Patrick J, Templeton K. Inclusion of Sex and Gender Differences in U.S. State Action Plans for Opioid Use and Opioid Use Disorder. J Womens Health (Larchmt) 2024; 33:275-282. [PMID: 38064491 DOI: 10.1089/jwh.2023.0232] [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] [Indexed: 03/13/2024] Open
Abstract
Background: States have developed action plans to address the "opioid crisis" over the past several years. While sex- and gender-based differences have been identified in complications of opioid use, risks of addiction to opioids, barriers to treatment of opioid use disorder, and associated stigma, it is unknown if or to what extent opioid plans consider or account for these differences. The objectives of this study were to analyze U.S. state opioid action plans and their inclusion of sex- and gender-specific concerns. Methods: A content analysis of 49 state plans was conducted in June 2020, assessing their inclusion of 14 variables covering provider education, pregnancy-related, and sex- or gender-based differences in opioid addiction and treatment. Results: Neonatal opioid withdrawal syndrome was the most common variable, noted in 57% of plans. Only 14% included pregnancy-related stigma, and 4% identified gender-specific stigma. Contraceptives and family-planning were included in 12% and 10% of plans, respectively. Two states included more than half of the variables and five plans made no mention of sex or gender differences. Conclusions: Few state plans contained sex- or gender-specific information, and those that did focused almost exclusively on childbearing, excluding other unique considerations of opioid-using-women of all ages. The results of this study could improve the care of women using opioids by informing the strategies of state agencies and impacting legislative efforts for prevention initiatives, substance use disorder treatment, and law enforcement programs.
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Affiliation(s)
- Taylor Goss
- Pennsylvania State University College of Medicine, State College, Pennsylvania, USA
| | - Jody Esguerra
- Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Connie Newman
- Department of Medicine, NYU School of Medicine, New York, New York, USA
| | - Jessica Patrick
- Department of Pediatrics, Louisiana State University School of Medicine, New Orleans, Louisiana, USA
| | - Kimberly Templeton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
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Brown HM, Roper SM, Dietzen DJ, Crews BO. High-sensitivity neonatal urine drug testing has similar positivity rates to meconium for detecting in utero exposure to methamphetamine and cocaine. J Anal Toxicol 2024; 48:99-103. [PMID: 37952088 DOI: 10.1093/jat/bkad085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 10/17/2023] [Accepted: 11/09/2023] [Indexed: 11/14/2023] Open
Abstract
Current guidelines recommend universal screening for substance use disorders in obstetric patients, and neonatal drug testing is also frequently performed. Meconium is often the preferred specimen type to detect neonatal drug exposure due to a longer window of detection compared to urine, but most laboratories send out meconium testing to specialized reference laboratories, which can delay results for several days or more. Here, we evaluate a rapid and definitive liquid chromatography-tandem mass spectrometry method for neonatal urine drug testing and compare results obtained using this method to paired meconium drug testing in 1,424 neonates for amphetamines, cocaine, cannabinoids, opiates, oxycodone and phencyclidine. Urine testing showed equivalent sensitivity to current meconium methods for detecting in utero exposure to amphetamines and cocaine.
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Affiliation(s)
- Hannah M Brown
- Department of Pathology & Immunology, Washington University School of Medicine, 425 So Euclid Ave., St. Louis, MO 63110, USA
| | - Stephen M Roper
- Department of Pathology & Immunology, Washington University School of Medicine, 425 So Euclid Ave., St. Louis, MO 63110, USA
- Department of Pediatrics, Washington University School of Medicine, 425 So Euclid Ave., St. Louis, MO 63110, USA
| | - Dennis J Dietzen
- Department of Pathology & Immunology, Washington University School of Medicine, 425 So Euclid Ave., St. Louis, MO 63110, USA
- Department of Pediatrics, Washington University School of Medicine, 425 So Euclid Ave., St. Louis, MO 63110, USA
| | - Bridgit O Crews
- Department of Pathology & Immunology, Washington University School of Medicine, 425 So Euclid Ave., St. Louis, MO 63110, USA
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Bedrick BS, Cary C, O'Donnell C, Marx C, Friedman H, Carter EB, Raghuraman N, Stout MJ, Ku BS, Xu KY, Kelly JC. County-level neonatal opioid withdrawal syndrome rates and real-world access to buprenorphine during pregnancy: An audit ("secret shopper") study in Missouri. DRUG AND ALCOHOL DEPENDENCE REPORTS 2024; 10:100218. [PMID: 38380272 PMCID: PMC10877162 DOI: 10.1016/j.dadr.2024.100218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/22/2024]
Abstract
Background Amid rising rates of neonatal opioid withdrawal syndrome (NOWS) worldwide and in many regions of the USA, we conducted an audit study ("secret shopper study") to evaluate the influence of county-level buprenorphine capacity and rurality on county-level NOWS rates. Methods In 2019, up to three phone calls were made to buprenorphine prescribers in the state of Missouri (USA). County-level buprenorphine capacity was defined as the number of clinicians (across all specialties) accepting pregnant people divided by the number of births. Multivariable negative binomial regression models estimated associations between buprenorphine capacity, rurality, and county-level NOWS rates, controlling for potential confounders (i.e., poverty, unemployment, and physician shortages) that may correspond to higher rates of NOWS and lower rates of buprenorphine prescribing. Analyses were stratified using tertiles of county-level overdose rates (top, middle, and lowest 1/3 of overdose rates). Results Of 115 Missouri counties, 81(70 %) had no buprenorphine capacity, 17(15 %) were low-capacity (<0.5-clinicians/1,000 births), and 17(15 %) were high-capacity (≥0.5/1,000 births). The mean NOWS rate was 6.5/1,000 births. In Missouri counties with both the highest and lowest opioid overdose rates, higher buprenorphine capacity did not correspond to decreases in NOWS rates (incidence rate ratio[IRR]=1.23[95 %-confidence-interval[CI]=0.65-2.32] and IRR=1.57[1.21-2.03] respectively). Rurality did not correspond to greater NOWS burden in both Missouri counties with highest and lowest opioid overdose rates. Conclusions The vast majority of counties in Missouri have no capacity for buprenorphine prescribing during pregnancy. Rurality and lower buprenorphine capacity did not significantly predict elevated rates of NOWS.
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Affiliation(s)
- Bronwyn S. Bedrick
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Caroline Cary
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO
| | - Carly O'Donnell
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Christine Marx
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Hayley Friedman
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Ebony B. Carter
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Nandini Raghuraman
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO
| | - Molly J. Stout
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI
| | - Benson S. Ku
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Kevin Y Xu
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
| | - Jeannie C. Kelly
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO
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Miller JS, Bada HS, Westgate PM, Sithisarn T, Leggas M. Neonatal Abstinence Signs during Treatment: Trajectory, Resurgence and Heterogeneity. CHILDREN (BASEL, SWITZERLAND) 2024; 11:203. [PMID: 38397314 PMCID: PMC10887053 DOI: 10.3390/children11020203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 01/28/2024] [Accepted: 01/28/2024] [Indexed: 02/25/2024]
Abstract
Neonatal abstinence syndrome (NAS) presents with a varying severity of withdrawal signs and length of treatment (LOT). We examined the course and relevance of each of the NAS withdrawal signs during treatment in a sample of 182 infants with any prenatal opioid exposure, gestational age ≥ 35 weeks, without other medical conditions, and meeting the criteria for pharmacological treatment. Infants were monitored using the Finnegan Neonatal Abstinence Scoring Tool. Daily mean Finnegan scores were estimated using linear mixed models with random subject effects to account for repeated withdrawal scores from the same subject. Daily item prevalence was estimated using generalized estimating equations with a within-subject exchangeable correlation structure. The median LOT was 12.86 days. The prevalence of withdrawal signs decreased from day one to day three of treatment. However, certain central nervous system (CNS) and gastrointestinal (GI) signs showed sporadic increases in prevalence notable around two weeks of treatment, accounting for increases in Finnegan scores that guided pharmacotherapy. We question whether the resurgence of signs with a prolonged LOT is mainly a consequence of opioid tolerance or withdrawal. Monitoring CNS and GI signs throughout treatment is crucial. Future studies directed to better understand this clinical phenomenon may lead to the refining of NAS pharmacotherapy and perhaps the discovery of treatment alternatives.
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Affiliation(s)
- Jennifer S. Miller
- College of Nursing, University of Tennessee, Knoxville, TN 37996, USA;
- College of Medicine, University of Kentucky, Lexington, KY 40536, USA;
| | - Henrietta S. Bada
- College of Medicine, University of Kentucky, Lexington, KY 40536, USA;
| | - Philip M. Westgate
- College of Public Health, University of Kentucky, Lexington, KY 40536, USA;
| | | | - Markos Leggas
- Division of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA;
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Sinkey RG, Ogunsile FJ, Kanter J, Bean C, Greenberg M. Society for Maternal-Fetal Medicine Consult Series #68: Sickle cell disease in pregnancy. Am J Obstet Gynecol 2024; 230:B17-B40. [PMID: 37866731 PMCID: PMC10961101 DOI: 10.1016/j.ajog.2023.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
Pregnant individuals with sickle cell disease have an increased risk of maternal and perinatal morbidity and mortality. However, prepregnancy counseling and multidisciplinary care can lead to favorable maternal and neonatal outcomes. In this consult series, we summarize what is known about sickle cell disease and provide guidance for sickle cell disease management during pregnancy. The following are Society for Maternal-Fetal Medicine recommendations.
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Chaiyachati BH, Deutsch SA. Improving health and well-being for infants with prenatal substance exposure. Curr Probl Pediatr Adolesc Health Care 2024; 54:101572. [PMID: 38431453 PMCID: PMC11025014 DOI: 10.1016/j.cppeds.2024.101572] [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: 03/05/2024]
Abstract
Substance use disorders (SUD) among caregiving adults has inexorable linkage to the health and well-being of millions of children in the U.S. This piece provides an overview of such linkages, examples of relevant policies and regulations, and the role of pediatric healthcare within the health trajectories of children and families at this intersection. A commonality throughout this work is need for non-stigmatizing engagement and support to facilitate connections to care and reduce barriers.
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Affiliation(s)
- Barbara H Chaiyachati
- Department of Pediatrics, Perelman School of Medicine, and Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA, USA; Division of General Pediatrics, Clinical Futures & Policy Lab, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Stephanie A Deutsch
- Department of Pediatrics, Nemours Children's Hospital, Delaware, Wilmington, DE, USA; Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
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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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Mascarenhas M, Wachman EM, Chandra I, Xue R, Sarathy L, Schiff DM. Advances in the Care of Infants With Prenatal Opioid Exposure and Neonatal Opioid Withdrawal Syndrome. Pediatrics 2024; 153:e2023062871. [PMID: 38178779 PMCID: PMC10827648 DOI: 10.1542/peds.2023-062871] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 01/06/2024] Open
Abstract
A significant number of advances have been made in the last 5 years with respect to the identification, diagnosis, assessment, and management of infants with prenatal opioid exposure and neonatal opioid withdrawal syndrome (NOWS) from birth to early childhood. The primary objective of this review is to summarize major advances that will inform the clinical management of opioid-exposed newborns and provide an overview of NOWS care to promote the implementation of best practices. First, advances with respect to standardizing the clinical diagnosis of NOWS will be reviewed. Second, the most commonly used assessment strategies are discussed, with a focus on presenting new quality improvement and clinical trial data surrounding the use of the new function-based assessment Eat, Sleep, and Console approach. Third, both nonpharmacologic and pharmacologic treatment modalities are reviewed, highlighting clinical trials that have compared the use of higher calorie and low lactose formula, vibrating crib mattresses, morphine compared with methadone, buprenorphine compared with morphine or methadone, the use of ondansetron as a medication to prevent the need for NOWS opioid pharmacologic treatment, and the introduction of symptom-triggered dosing compared with scheduled dosing. Fourth, maternal, infant, environmental, and genetic factors that have been found to be associated with NOWS severity are highlighted. Finally, emerging recommendations on postdelivery hospitalization follow-up and developmental surveillance are presented, along with highlighting ongoing and needed areas of research to promote infant and family well-being for families impacted by opioid use.
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Affiliation(s)
| | - Elisha M. Wachman
- Department of Pediatrics, Boston Medical Center, and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Iyra Chandra
- Dana Farber Cancer Institute, Boston, Massachusetts
| | - Rachel Xue
- Department of Family Medicine, Boston Medical Center, Boston, Massachusetts
| | - Leela Sarathy
- Newborn Medicine, MassGeneral for Children, Boston, Massachusetts
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Schiff DM, Muftu S, MacMillan KDL, Work EC, Hoeppner BB, Greenfield SF, Schwartz L, Chaiyachati B, Wilens TE, Bernstein JA. Mutual Mistrust: The Multilayered Experiences at the Intersection of Healthcare and Early Parenting Among Mothers With Opioid Use Disorder. J Addict Med 2024; 18:55-61. [PMID: 37994464 PMCID: PMC10872799 DOI: 10.1097/adm.0000000000001242] [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] [Indexed: 11/24/2023]
Abstract
OBJECTIVE The aim of the study is to explore the early parenting experiences among a cohort of postpartum individuals with opioid use disorder (OUD) both during and after the delivery hospitalization to identify areas of intervention to strengthen bonding and attachment. METHODS Semistructured qualitative interviews with recently pregnant people with OUD assessed parenting needs, supports, and goals in the context of the demands of addiction treatment and early motherhood. Probes explored the relationship between early parenting experiences, addiction, and recovery, as well as enabling factors and barriers to mother-infant bonding. Interviews were completed between 2019 to 2020. A constant comparative methods approach was used for codebook development and analysis. RESULTS Twenty-six women completed interviews a mean of 10.1 months postpartum. Twenty-four women were receiving methadone or buprenorphine treatment at delivery for OUD. Four interrelated themes emerged. Women experienced the following: (1) increased surveillance from healthcare workers who doubted their parenting ability; (2) a desire for a "normal" early parenting experience that was not disrupted by increased medical monitoring and surveillance; (3) complex and intersecting identities of being both a mother and a person in recovery; and (4) the importance of support from and advocacy by clinicians and peers to developing maternal confidence and connection. CONCLUSIONS Interventions are needed to improve the early parenting experiences of opioid-exposed mother-infant dyads, to address the mutual mistrust between health care providers and parents, and to provide additional supports to families. Promotion of positive attachment and parental self-efficacy should be prioritized over increased surveillance and scrutiny to sustain maternal recovery trajectories into early childhood and foster family well-being.
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Affiliation(s)
- Davida M. Schiff
- Division of General Academic Pediatrics, MassGeneral Hospital for Children, 125 Nashua St Suite 860, Boston, Massachusetts, 02114
| | - Serra Muftu
- Division of General Academic Pediatrics, MassGeneral Hospital for Children, 125 Nashua St Suite 860, Boston, Massachusetts, 02114
| | | | - Erin C. Work
- Division of General Academic Pediatrics, MassGeneral Hospital for Children, 125 Nashua St Suite 860, Boston, Massachusetts, 02114
| | - Bettina B. Hoeppner
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit St, Boston, Massachusetts, 02114
| | - Shelly F. Greenfield
- Division of Women’s Mental Health and Division of Alcohol, Drugs, and Addiction, McLean Hospital, 115 Mill St, Belmont, MA 02478
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115
| | - Leah Schwartz
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115
| | - Barbara Chaiyachati
- Department of Pediatrics, Perelman School of Medicine, and Leonard Davis Institute, University of Pennsylvania
- Division of General Pediatrics, PolicyLab and Clinical Futures, Children’s Hospital of Philadelphia
| | - Timothy E. Wilens
- Division of Child and Adolescent Psychiatry, Massachusetts General Hospital, 55 Fruit St, Boston, Massachusetts, 02114
| | - Judith A. Bernstein
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA
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Bhatt-Mehta V, Jing X, Wang X, Zhu HJ. Transplacental methadone exposure and risk of Neonatal Opioid Withdrawal Syndrome. Pharmacotherapy 2024; 44:22-27. [PMID: 37574548 DOI: 10.1002/phar.2863] [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: 04/14/2023] [Revised: 06/18/2023] [Accepted: 06/22/2023] [Indexed: 08/15/2023]
Abstract
STUDY OBJECTIVE Neonatal opioid withdrawal syndrome (NOWS) is a condition that often occurs in neonates born to mothers who received methadone treatment for opioid use disorder during pregnancy. Early identification and treatment of infants at risk of NOWS may improve clinical outcomes. The purpose of this study was to evaluate whether maternal and umbilical cord plasma concentrations of methadone and its metabolite, 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP), could predict the need for NOWS treatment. DESIGN Single-center prospective study. SETTING University of Michigan Neonatal Intensive Care Unit. PATIENTS The study included 11 opioid-dependent mother-infant dyads, where the mothers were treated with methadone at 34 weeks' gestation or later. INTERVENTION Maternal and cord blood samples were collected from the study participants. MEASUREMENTS AND MAIN RESULTS Maternal and cord plasma concentrations of methadone and EDDP were determined. Six out of the 11 infants required treatment for NOWS. Maternal methadone plasma concentrations were comparable between infants requiring and not requiring NOWS treatment (329.1 ± 229.7 ng/mL vs. 413.2 ± 329.8 ng/mL). However, the average cord plasma methadone concentration in infants who did not require NOWS treatment was 2.9-fold higher than in those who required the treatment (120.0 ± 88.6 ng/mL vs. 40.9 ± 24.4 ng/mL), although the difference was not statistically significant. The ratios of maternal-to-cord methadone plasma concentrations were significantly higher in patients who required treatment for NOWS compared with those who did not (7.7 ± 1.9 vs. 3.5 ± 1.6, p = 0.003). Maternal and cord plasma EDDP concentrations and the maternal-to-cord plasma EDDP concentration ratios did not differ between patients who required and did not require treatment for NOWS. CONCLUSIONS The results suggest that methadone permeability across the blood-placental barrier may affect in utero exposure to methadone, and the maternal-to-cord methadone plasma concentration ratio could be a potential biomarker for predicting the need for NOWS treatment.
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Affiliation(s)
- Varsha Bhatt-Mehta
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Xinyue Jing
- Key Laboratory of Acupuncture and Medicine Research of Ministry of Education, Nanjing University of Chinese Medicine, Nanjing, China
| | - Xinwen Wang
- Department of Pharmaceutical Sciences, Northeast Ohio Medical University, Rootstown, Ohio, USA
| | - Hao-Jie Zhu
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
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Nyman K, Okolie F, Davis NL, Hager E, El-Metwally D. Implicit Racial Bias in Evaluation of Neonatal Opioid Withdrawal Syndrome. J Racial Ethn Health Disparities 2023:10.1007/s40615-023-01887-w. [PMID: 38110799 DOI: 10.1007/s40615-023-01887-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/20/2023] [Accepted: 11/29/2023] [Indexed: 12/20/2023]
Abstract
OBJECTIVE To assess implicit bias by administrating the Modified Finnegan Score (MFS) for quantifying neonatal opioid withdrawal and to evaluate risk of decreased opioid treatment of Black versus White infants. STUDY DESIGN Study participants were nurses recruited from a large tertiary care center who received three clinical vignettes portraying withdrawing infants and were randomized to receive an accompanying photo of either a Black or White infant. MFS results were compared for identical vignettes based on race of infant photo. RESULTS Out of 275 nurses, 70 completed the survey. In vignette 2, nurses aged ≤35 years scored Black infants lower than White infants (MFS=8.3 ± 2 vs. 9.5 ± 1.2, p=0.012). Nurses with <5 years of experience and ≤10 years of experience also scored Black infants lower for the same vignette (8.2 ± 2.3 vs. 9.6 ± 1.2, p=0.032 and 8.3 ± 2 vs. 9.5 ± 1.2, p=0.0083). CONCLUSION Implicit bias may contribute to the difference in opioid treatment.
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Affiliation(s)
- Katherine Nyman
- University of California San Diego School of Medicine, San Diego, CA, USA
- Division of Neonatology, Rady Children's Hospital, San Diego, CA, USA
| | - Francesca Okolie
- University of Maryland Medical Center, Baltimore, MD, USA
- Department of Pediatrics, University of Maryland School of Medicine, 110 South Paca Street, 8th Floor, Baltimore, MD, S-512, USA
| | - Natalie L Davis
- University of Maryland Medical Center, Baltimore, MD, USA
- Department of Pediatrics, University of Maryland School of Medicine, 110 South Paca Street, 8th Floor, Baltimore, MD, S-512, USA
| | - Erin Hager
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Dina El-Metwally
- University of Maryland Medical Center, Baltimore, MD, USA.
- Department of Pediatrics, University of Maryland School of Medicine, 110 South Paca Street, 8th Floor, Baltimore, MD, S-512, USA.
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Borrelli KN, Wingfield KK, Yao EJ, Zamorano CA, Sena KD, Beierle JA, Roos MA, Zhang H, Wachman EM, Bryant CD. Decreased myelin-related gene expression in the nucleus accumbens during spontaneous neonatal opioid withdrawal in the absence of long-term behavioral effects in adult outbred CFW mice. Neuropharmacology 2023; 240:109732. [PMID: 37774943 PMCID: PMC10598517 DOI: 10.1016/j.neuropharm.2023.109732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/23/2023] [Accepted: 09/25/2023] [Indexed: 10/01/2023]
Abstract
Prenatal opioid exposure is a major health concern in the United States, with the incidence of neonatal opioid withdrawal syndrome (NOWS) escalating in recent years. NOWS occurs upon cessation of in utero opioid exposure and is characterized by increased irritability, disrupted sleep patterns, high-pitched crying, and dysregulated feeding. The main pharmacological strategy for alleviating symptoms is treatment with replacement opioids. The neural mechanisms mediating NOWS and the long-term neurobehavioral effects are poorly understood. We used a third trimester-approximate model in which neonatal outbred pups (Carworth Farms White; CFW) were administered once-daily morphine (15 mg/kg, s.c.) from postnatal day (P) day 1 through P14 and were then assessed for behavioral and transcriptomic adaptations within the nucleus accumbens (NAc) on P15. We also investigated the long-term effects of perinatal morphine exposure on adult learning and reward sensitivity. We observed significant weight deficits, spontaneous thermal hyperalgesia, and altered ultrasonic vocalization (USV) profiles following repeated morphine and during spontaneous withdrawal. Transcriptome analysis of NAc from opioid-withdrawn P15 neonates via bulk mRNA sequencing identified an enrichment profile consistent with downregulation of myelin-associated transcripts. Despite the neonatal behavioral and molecular effects, there were no significant long-term effects of perinatal morphine exposure on adult spatial memory function in the Barnes Maze, emotional learning in fear conditioning, or in baseline or methamphetamine-potentiated reward sensitivity as measured via intracranial self-stimulation. Thus, the once daily third trimester-approximate exposure regimen, while inducing NOWS model traits and significant transcriptomic effects in neonates, had no significant long-term effects on adult behaviors.
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Affiliation(s)
- Kristyn N Borrelli
- Graduate Program for Neuroscience, Boston University, 610 Commonwealth Av, Boston, MA, 02215, USA; T32 Biomolecular Pharmacology PhD Program, Boston University Chobanian & Avedisian School of Medicine, USA; Boston University's Transformative Training Program in Addiction Science, Boston University Chobanian & Avedisian School of Medicine, 72 E. Concord St., L-317, Boston, MA, 02118, USA
| | - Kelly K Wingfield
- T32 Biomolecular Pharmacology PhD Program, Boston University Chobanian & Avedisian School of Medicine, USA; Laboratory of Addiction Genetics, Department of Pharmacology, Physiology & Biophysics, Boston University Chobanian & Avedisian School of Medicine, 72 E. Concord St., L-606, Boston, MA, 02118, USA; Department of Pharmaceutical Sciences, Center for Drug Discovery, Northeastern University, 360 Huntington Av, 140 The Fenway Building, X138, Boston, MA, 02115, USA
| | - Emily J Yao
- Laboratory of Addiction Genetics, Department of Pharmacology, Physiology & Biophysics, Boston University Chobanian & Avedisian School of Medicine, 72 E. Concord St., L-606, Boston, MA, 02118, USA; Department of Pharmaceutical Sciences, Center for Drug Discovery, Northeastern University, 360 Huntington Av, 140 The Fenway Building, X138, Boston, MA, 02115, USA
| | - Catalina A Zamorano
- Boston University's Undergraduate Research Opportunity Program, George Sherman Union, 775 Commonwealth Av, 5th floor, Boston, MA, 02215, USA
| | - Katherine D Sena
- Boston University's Undergraduate Research Opportunity Program, George Sherman Union, 775 Commonwealth Av, 5th floor, Boston, MA, 02215, USA
| | - Jacob A Beierle
- T32 Biomolecular Pharmacology PhD Program, Boston University Chobanian & Avedisian School of Medicine, USA; Boston University's Transformative Training Program in Addiction Science, Boston University Chobanian & Avedisian School of Medicine, 72 E. Concord St., L-317, Boston, MA, 02118, USA; Laboratory of Addiction Genetics, Department of Pharmacology, Physiology & Biophysics, Boston University Chobanian & Avedisian School of Medicine, 72 E. Concord St., L-606, Boston, MA, 02118, USA; Department of Pharmaceutical Sciences, Center for Drug Discovery, Northeastern University, 360 Huntington Av, 140 The Fenway Building, X138, Boston, MA, 02115, USA
| | - Michelle A Roos
- Laboratory of Addiction Genetics, Department of Pharmacology, Physiology & Biophysics, Boston University Chobanian & Avedisian School of Medicine, 72 E. Concord St., L-606, Boston, MA, 02118, USA; Department of Pharmaceutical Sciences, Center for Drug Discovery, Northeastern University, 360 Huntington Av, 140 The Fenway Building, X138, Boston, MA, 02115, USA
| | - Huiping Zhang
- Department of Psychiatry, Boston University Chobanian and Avedisian School of Medicine, 72 E. Concord St., Boston, MA, 02118, USA
| | - Elisha M Wachman
- Department of Pediatrics, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, 1 Boston Medical Center Pl, Boston, MA, 02118, USA
| | - Camron D Bryant
- Laboratory of Addiction Genetics, Department of Pharmacology, Physiology & Biophysics, Boston University Chobanian & Avedisian School of Medicine, 72 E. Concord St., L-606, Boston, MA, 02118, USA; Department of Pharmaceutical Sciences, Center for Drug Discovery, Northeastern University, 360 Huntington Av, 140 The Fenway Building, X138, Boston, MA, 02115, USA.
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Elmore AL, Salemi JL, Kirby RS, Sappenfield WM, Lowry J, Dixon A, Lake-Burger H, Tanner JP. Evaluation of Administrative Data for Identifying Maternal Opioid Use at Delivery in Florida. Matern Child Health J 2023; 27:44-51. [PMID: 37199857 PMCID: PMC10692249 DOI: 10.1007/s10995-023-03669-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 05/19/2023]
Abstract
OBJECTIVES Studies have shown significant increases in the prevalence of maternal opioid use. Most prevalence estimates are based on unverified ICD-10-CM diagnoses. This study determined the accuracy of ICD-10-CM opioid-related diagnosis codes documented during delivery and examined potential associations between maternal/hospital characteristics and diagnosis with an opioid-related code. METHODS To identify people with prenatal opioid use, we identified a sample of infants born during 2017-2018 in Florida with a NAS related diagnosis code (P96.1) and confirmatory NAS characteristics (N = 460). Delivery records were scanned for opioid-related diagnoses and prenatal opioid use was confirmed through record review. The accuracy of each opioid-related code was measured using positive predictive value (PPV) and sensitivity. Modified Poisson regression was used to calculate adjusted relative risks (aRR) and 95% confidence intervals (CI). RESULTS We found the PPV was nearly 100% for all ICD-10-CM opioid-related codes (98.5-100%) and the sensitivity was 65.9%. Non-Hispanic Black mothers were 1.8 times more likely than non-Hispanic white mothers to have a missed opioid-related diagnosis at delivery (aRR:1.80, CI 1.14-2.84). Mothers who delivered at a teaching status hospital were less likely to have a missed opioid-related diagnosis (p < 0.05). CONCLUSIONS FOR PRACTICE We observed high accuracy of maternal opioid-related diagnosis codes at delivery. However, our findings suggest that over 30% of mothers with opioid use may not be diagnosed with an opioid-related code at delivery, although their infant had a confirmed NAS diagnosis. This study provides information on the utility and accuracy of ICD-10-CM opioid-related codes at delivery among mothers of infants with NAS.
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Affiliation(s)
- Amanda L Elmore
- Chiles Center, College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC56, Tampa, FL, 33612-3805, USA.
| | - Jason L Salemi
- Chiles Center, College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC56, Tampa, FL, 33612-3805, USA
| | - Russell S Kirby
- Chiles Center, College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC56, Tampa, FL, 33612-3805, USA
| | - William M Sappenfield
- Chiles Center, College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC56, Tampa, FL, 33612-3805, USA
| | - Joseph Lowry
- Florida Department of Health, Florida Birth Defects Registry, Tallahassee, USA
| | - Ashley Dixon
- Chiles Center, College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC56, Tampa, FL, 33612-3805, USA
| | - Heather Lake-Burger
- Florida Department of Health, Florida Birth Defects Registry, Tallahassee, USA
| | - Jean Paul Tanner
- Chiles Center, College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC56, Tampa, FL, 33612-3805, USA
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Duka S, Rahman S, Hansen SE, Esernio-Jenssen D. The Effect of Maternal Adverse Childhood Experiences (ACEs) on Substance Use During Pregnancy. Matern Child Health J 2023; 27:153-165. [PMID: 37733152 PMCID: PMC10691987 DOI: 10.1007/s10995-023-03768-4] [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] [Accepted: 08/22/2023] [Indexed: 09/22/2023]
Abstract
OBJECTIVES To analyze adverse childhood experiences (ACEs) among mothers of newborns referred to a hospital's child protection team (CPT) for suspected substance exposure. Researchers hypothesized that a higher prevalence of these mothers have ≥ 4 ACEs than female counterparts in the general population. The study team also explored whether associations existed between type of maternal ACEs and substance use in pregnancy. METHODS Retrospective review of infant referrals to the CPT in the 3 years after adding an ACEs questionnaire to the consultation process. Bivariate analyses and multivariate logistic regression models examined associations between prenatal substance use and maternal ACEs prevalence, controlling for demographics. RESULTS Data from 222 infants (four sets of twins) and 218 mothers were analyzed. Half (50.0%) the infants had withdrawal symptoms. Most (67.0%) women had positive toxicology screens, while 85.0% reported prenatal substance use. Half (50.9%) the mothers reported ≥ 4 ACEs and these individuals had significantly higher odds of cannabinoid use [adjusted odds ratio (aOR), 3.7; 95%CI 2.0, 6.9, p < 0.001) than those with < 4 ACEs. A significant association was found between substance use and ACEs in the household challenges category (p = 0.03), especially parental separation/divorce (p < 0.001). CONCLUSIONS FOR PRACTICE As hypothesized, a higher prevalence of mothers referred to the CPT had ≥ 4 ACEs than women in the general population (50.9% vs. 15.2%), and a large proportion had used substances while pregnant. Routine prenatal ACEs screening and universal, nonpunitive toxicology testing of infants and mothers at birth may provide opportunities for intervention while reducing the transgenerational impact of ACEs.
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Affiliation(s)
- Shae Duka
- Network Office of Research and Innovation, Lehigh Valley Health Network, Allentown, USA
- Morsani College of Medicine, University of South Florida, Tampa, USA
| | - Sadeea Rahman
- Department of Pediatrics, Jacobi Medical Center, New York, USA
| | - Susan E Hansen
- Network Office of Research and Innovation, Lehigh Valley Health Network, Allentown, USA
- Morsani College of Medicine, University of South Florida, Tampa, USA
| | - Debra Esernio-Jenssen
- Morsani College of Medicine, University of South Florida, Tampa, USA.
- Department of Pediatrics, Lehigh Valley Health Network, Allentown, USA.
- Lehigh Valley Reilly Children's Hospital, Cedar Crest Boulevard and I-78, Allentown, PA, 18103, USA.
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Gersch H, Shah D, Chroust A, Bailey B. Can umbilical cord testing add to maternal urine drug screen for evaluation of infants at risk of neonatal opioid withdrawal syndrome? J Matern Fetal Neonatal Med 2023; 36:2211706. [PMID: 37183045 DOI: 10.1080/14767058.2023.2211706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
OBJECTIVE This study evaluated maternal urine drug screen (UDS) at delivery and umbilical cord drug testing and its association with neonatal opioid withdrawal syndrome (NOWS) diagnosis and severity following opioid exposed pregnancy. METHODS A retrospective chart review of 770 mother-infant dyads at five birthing hospitals in the United States Appalachian region for a five-year period was performed. Variables of interest included dyad demographics, results of maternal UDS at delivery and umbilical cord drug testing, and three neonatal outcomes: NOWS diagnosis, pharmacologic treatment administered for NOWS, and length of hospital stay (LOS) of the newborn. RESULTS Opioid-positivity was between 8.5% and 66.3% based on maternal UDS at delivery or umbilical cord testing. Odds of NOWS diagnosis and increased infant LOS was best associated with opioid detection in maternal UDS alone (OR = 5.62, 95% CI [3.06, 10.33] and OR = 8.33, 95% CI [3.67, 18.89], respectively). However, odds of pharmacologic treatment for NOWS was best associated with opioid detection in both maternal UDS and umbilical cord testing on the same dyad (OR = 3.22, 95% CI [1.14, 9.09]). CONCLUSION Maternal UDS is a better option compared to umbilical cord testing for evaluation of opioid-exposed infants and risk of NOWS diagnosis and increased infant LOS.
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Affiliation(s)
- Hannah Gersch
- Department of Pediatrics, Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Darshan Shah
- Department of Pediatrics, Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Alyson Chroust
- Department of Psychology, College of Arts and Sciences, East Tennessee State University, Johnson City, TN, USA
| | - Beth Bailey
- Department of Pediatrics, Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
- College of Medicine, Central Michigan University, Mt. Pleasant, MI, USA
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Wei Z, Gilbert Y, Thananjeyan A, Cope J, Morton RL, Li A, Pham CT, Ward M, Oei JL. A Systematic Review of Clinical Practice Guidelines for Neonatal Abstinence Syndrome. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1685. [PMID: 37892348 PMCID: PMC10605060 DOI: 10.3390/children10101685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/09/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND The prevalence of neonatal abstinence syndrome is increasing, but the number and quality of clinical practice guidelines available are unknown. This systematic review aimed to identify, appraise and evaluate clinical practice guidelines for neonatal abstinence syndrome. METHODS A systematic search of databases and the grey literature was conducted between 1 June and 1 July 2022. Full-text guidelines published by national or state-wide institutions were included. The recommendations from each guideline were extracted. The AGREE-II instrument was used to assess guideline quality. Sufficient-quality scores were defined as >60 and good-quality scores were >80 for each domain of AGREE-II. RESULTS A total of 1703 records were identified, and 22 guidelines from the United States, Australia, Canada and the United Kingdom, published between 2012 to 2021, were included. The quality scores were low, with median scores of 37/100 for stakeholder involvement, 33/100 for methodology, 34/100 for applicability and 0 for editorial independence. Scope and purpose scored 72/100, and presentation scored 85/100. Sixteen (73%) guidelines did not meet the cut-offs for clinical use. CONCLUSION Many guidelines were of insufficient quality to guide clinical practice for neonatal abstinence syndrome. This emphasises the need for high-quality studies to inform clinical practice guidelines, improve care and reduce the risk of poor outcomes in these high-risk infants.
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Affiliation(s)
- Zoe Wei
- School of Women’s and Children’s Health, Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia; (Z.W.)
| | - Yasmin Gilbert
- School of Women’s and Children’s Health, Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia; (Z.W.)
- Prince of Wales Hospital, Barker Street, Randwick, Sydney, NSW 2031, Australia
| | - Arabhi Thananjeyan
- School of Women’s and Children’s Health, Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia; (Z.W.)
| | - James Cope
- School of Women’s and Children’s Health, Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia; (Z.W.)
| | - Rachael L. Morton
- National Health and Medical Research Council Clinical Trials Centre, The University of Sydney, 92–94 Parramatta Road, Camperdown, Sydney, NSW 2006, Australia
| | - Annie Li
- School of Women’s and Children’s Health, Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia; (Z.W.)
| | - Cecile T. Pham
- School of Women’s and Children’s Health, Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia; (Z.W.)
| | - Meredith Ward
- School of Women’s and Children’s Health, Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia; (Z.W.)
- Department of Newborn Care, The Royal Hospital for Women, Barker Street, Randwick, Sydney, NSW 2031, Australia
| | - Ju Lee Oei
- School of Women’s and Children’s Health, Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia; (Z.W.)
- Department of Newborn Care, The Royal Hospital for Women, Barker Street, Randwick, Sydney, NSW 2031, Australia
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45
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Miller JS, Bada H, Dunworth C, Charnigo R. Recent and lifetime maternal substance use: Rurality and economic distress. Res Nurs Health 2023; 46:502-514. [PMID: 37515582 PMCID: PMC10528337 DOI: 10.1002/nur.22330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 07/10/2023] [Accepted: 07/15/2023] [Indexed: 07/31/2023]
Abstract
Research on opioid use disorder (OUD) in pregnancy has mainly considered women in urban areas receiving treatment, with less known about women in rural areas. We sought to describe demographics and substance use characteristics of pregnant women with OUD and to compare the women based on urbanicity, in a state (Kentucky) with unfavorable economic conditions in many rural counties; we hypothesized that pregnant women in rural areas would have greater adversity, broadly defined, related to substance use. Using data collected from a larger project between 2017 and 2020, we analyzed characteristics of 93 pregnant women (59 rural and 34 urban) with OUD; we examined data in medical, employment, substance use, legal, family history, relationship, and psychiatric health domains, both overall and within rural (population <50,000) and urban (population ≥50,000) strata. Pregnant women with OUD from rural and urban areas were similar on almost all attributes. Among the few significant differences, 30% from urban areas perceived inadequate prenatal care versus 11% from rural areas (p = 0.024); 21% of urban women used amphetamines/methamphetamines in the month before delivery versus 0% of rural women (p < 0.001); and rural women had longer most recent abstinence from substance use than their urban counterparts (medians 7.0 and 2.8 months, p = 0.049). The few significant differences that were discovered favored rural women. These findings, contrary to our hypothesis, suggest that tailoring interventions may require more than focusing on geography. The participants in this study were pregnant women being treated for OUD, and as such there is patient contribution of data.
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Affiliation(s)
- Jennifer Shearer Miller
- College of Medicine, University of Kentucky, Lexington, KY
- College of Nursing, University of Tennessee, Knoxville, TN
| | - Henrietta Bada
- College of Medicine, University of Kentucky, Lexington, KY
| | - Caitlin Dunworth
- KCH Office of Pediatric Research, Kentucky Children’s Hospital, Lexington, KY
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Harris M, Schiff DM, Saia K, Muftu S, Standish KR, Wachman EM. Academy of Breastfeeding Medicine Clinical Protocol #21: Breastfeeding in the Setting of Substance Use and Substance Use Disorder (Revised 2023). Breastfeed Med 2023; 18:715-733. [PMID: 37856658 PMCID: PMC10775244 DOI: 10.1089/bfm.2023.29256.abm] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
Background: The Academy of Breastfeeding Medicine (ABM) revised the 2015 version of the substance use disorder (SUD) clinical protocol to review the evidence and provide updated literature-based recommendations related to breastfeeding in the setting of substance use and SUD treatments. Key Information: Decisions around breastfeeding are an important aspect of care during the peripartum period, and there are specific benefits and risks for substance-exposed mother-infant dyads. Recommendations: This protocol provides breastfeeding recommendations in the setting of nonprescribed opioid, stimulant, sedative-hypnotic, alcohol, nicotine, and cannabis use, and SUD treatments. Additionally, we offer guidance on the utility of toxicology testing in breastfeeding recommendations. Individual programs and institutions should establish consistent breastfeeding approaches that mitigate bias, facilitate consistency, and empower mothers with SUD. For specific breastfeeding recommendations, given the complexity of breastfeeding in mothers with SUD, individualized care plans should be created in partnership with the patient and multidisciplinary team with appropriate clinical support and follow-up. In general, breastfeeding is recommended among mothers who stop nonprescribed substance use by the time of delivery, and they should continue to receive ongoing postpartum care, such as lactation support and SUD treatment. Overall, enhancing breastfeeding education regarding substance use in pregnancy and lactation is essential to allow for patient-centered guidance.
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Affiliation(s)
- Miriam Harris
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
- Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts, USA
| | - Davida M. Schiff
- Divisions of Newborn Medicine and Mass General Hospital for Children, Boston, Massachusetts, USA
- Divisions of General Academic Pediatrics, Mass General Hospital for Children, Boston, Massachusetts, USA
| | - Kelley Saia
- Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts, USA
- Department of Obstetrics and Gynecology, Chobanian & Avedisian Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Serra Muftu
- Divisions of Newborn Medicine and Mass General Hospital for Children, Boston, Massachusetts, USA
- Divisions of General Academic Pediatrics, Mass General Hospital for Children, Boston, Massachusetts, USA
| | - Katherine R. Standish
- Department of Family Medicine, and Chobanian & Avedisian Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Elisha M. Wachman
- Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts, USA
- Department of Pediatrics, Chobanian & Avedisian Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
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47
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Nyman KN, Driscoll CH. Apnea in a Newborn. Pediatr Rev 2023; 44:S69-S71. [PMID: 37777214 DOI: 10.1542/pir.2021-005491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Affiliation(s)
| | - Colleen Hughes Driscoll
- University of Maryland Medical Center, Baltimore, MD
- University of Maryland School of Medicine, Baltimore, MD
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Wilkinson A, Rackers HS, Harmon TM. Developmental implications of prenatal opioid exposure among school-aged children: a mixed methods and community-initiated analysis. BMC Public Health 2023; 23:1815. [PMID: 37723494 PMCID: PMC10507820 DOI: 10.1186/s12889-023-16702-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 09/05/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Growing research points to potential long-term developmental implications of prenatal opioid exposure for children. Yet, polysubstance use and adverse childhood experiences are raised as potential confounders. Further, there is a lack of data on school-age children and the children's strengths. METHODS Parents and caregivers of children with prenatal opioid exposure worked with the study team to design, collect, and descriptively analyze mixed method data. Data were collected through survey (n = 148) and two focus groups (n = 15) from a convenience sample in mostly West Virginia and Massachusetts. RESULTS Nearly half of the children in the sample were diagnosed with multiple developmental delays, behavioral health conditions, and specific learning disorders. Roughly 85% of children have behavioral challenges. Associations between prenatal opioid exposure and negative developmental outcomes did not vary by type of opioid nor by polysubstance use, while controlling for adverse childhood experiences. Importantly, over 80% of families also reported their child's strengths, including empathy, social magnetism, and their resilience. CONCLUSIONS The challenges for children born with prenatal opioid exposure may extend into school-age. The results are consistent with prior research on younger children, suggesting a need for best practices for caring for these children beyond the neonatal stage.
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Affiliation(s)
- Andra Wilkinson
- Child Trends, Inc, 1516 E Franklin St, Chapel Hill, NC, 27514, USA.
| | - H S Rackers
- Child Trends, Inc, 1516 E Franklin St, Chapel Hill, NC, 27514, USA
| | - T M Harmon
- To The Moon And Back, PO Box 1078, Plymouth, MA, 02362, USA
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Camden A, To T, Gomes T, Ray J, Bai L, Guttmann A. Prenatal opioid exposure and well-child care in the first 2 years of life: population-based cohort study. Arch Dis Child 2023; 108:754-761. [PMID: 37308290 PMCID: PMC10447387 DOI: 10.1136/archdischild-2022-325029] [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: 10/17/2022] [Accepted: 05/26/2023] [Indexed: 06/14/2023]
Abstract
OBJECTIVES To quantify well-child visits by age 2 years and developmental screening at the 18-month enhanced well-child visit among children with prenatal opioid exposure (POE) and to identify factors associated with study outcomes. DESIGN Population-based cohort study. SETTING Ontario, Canada. PARTICIPANTS 22 276 children with POE born 2014-2018 were classified as (1) 1-29 days of prescribed opioid analgesia, (2) 30+ days of prescribed opioid analgesia, (3) medication for opioid use disorder (MOUD), (4) MOUD and opioid analgesia, or (5) unregulated opioids. MAIN OUTCOME MEASURES Attending ≥5 well-child visits by age 2 years and the 18-month enhanced well-child visit. Modified Poisson regression was used to examine factors associated with outcomes. RESULTS Children with POE to 1-29 days of analgesics were most likely to attend ≥5 well-child visits (61.2%). Compared with these children, adjusted relative risks (aRRs) for ≥5 well-child visits were lower among those exposed to 30+ days of opioid analgesics (0.95, 95% CI 0.91 to 0.99), MOUD (0.83, 95% CI 0.79 to 0.88), MOUD and opioid analgesics (0.78 95% CI 0.68 to 0.90) and unregulated opioids (0.89, 95% CI 0.83 to 0.95). Relative to children with POE to 1-29 days of analgesics (58.5%), respective aRRs for the 18-month enhanced well-child visit were 0.92 (95% CI 0.88 to 0.96), 0.76 (95% CI 0.72 to 0.81), 0.76 (95% CI 0.66 to 0.87) and 0.82 (95% CI 0.76 to 0.88). Having a regular primary care provider was positively associated with study outcomes; socioeconomic disadvantage, rurality and maternal mental health were negatively associated. CONCLUSION Well-child visits are low in children following POE, especially among offspring of mothers receiving MOUD or unregulated opioids. Strategies to improve attendance will be important for child outcomes.
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Affiliation(s)
- Andi Camden
- Dalla Lana School of Public Health, Division of Epidemiology, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Teresa To
- Dalla Lana School of Public Health, Division of Epidemiology, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Tara Gomes
- ICES, Toronto, Ontario, Canada
- Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, and Edwin SH Leong Centre for Healthy Children, University of Toronto, Toronto, Ontario, Canada
| | - Joel Ray
- ICES, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Li Bai
- ICES, Toronto, Ontario, Canada
| | - Astrid Guttmann
- Dalla Lana School of Public Health, Division of Epidemiology, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Obstetrics and Gynaecology, St. Michaels Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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50
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Patz C, Liviskie C, Bird M, Zeller B, Vesoulis ZA, Smyser CD, McPherson C. Gabapentin as Adjunctive Therapy in Neonatal Opioid Withdrawal Syndrome: A Case Series. J Pediatr Pharmacol Ther 2023; 28:368-373. [PMID: 37795276 PMCID: PMC10547049 DOI: 10.5863/1551-6776-28.4.368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/01/2022] [Indexed: 10/06/2023]
Abstract
OBJECTIVE We describe a single center experience with gabapentin as adjunctive therapy in infants with neonatal opioid withdrawal syndrome (NOWS). METHODS We performed a retrospective chart review of infants receiving gabapentin for NOWS. Data points collected included patient's sex, gestational age, maternal opioid exposure, NOWS medication dosing and length of therapy, number of failed wean attempts, time to successful morphine wean and duration of morphine wean, length of stay in the neonatal intensive care unit (NICU), and NOWS medications at discharge. RESULTS Six infants received gabapentin as adjunctive treatment for NOWS. All infants failed 2-4 morphine weans before initiation of gabapentin despite the addition of clonidine. All infants that received gabapentin were successfully weaned off morphine. The time to wean off morphine after gabapentin initiation varied from 4-35 days. Maximum gabapentin doses ranged from 15 - 42.7 mg/kg/day. Five infants were discharged from the NICU on gabapentin. CONCLUSIONS Gabapentin appeared to facilitate successful morphine weans in six patients with NOWS who were previously unable to wean despite the initiation of clonidine.
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Affiliation(s)
- Caroline Patz
- Department of Pharmacy (CP, CL, BZ, CM), St. Louis Children’s Hospital, St. Louis, MO
| | - Caren Liviskie
- Department of Pharmacy (CP, CL, BZ, CM), St. Louis Children’s Hospital, St. Louis, MO
| | - Merielle Bird
- Department of Neurology (MB, CDS), Washington University School of Medicine, St. Louis, MO
- Department of Pediatrics (MB, CDS), Washington University School of Medicine, St. Louis, MO
| | - Brandy Zeller
- Department of Pharmacy (CP, CL, BZ, CM), St. Louis Children’s Hospital, St. Louis, MO
- Department of Neurology (MB, CDS), Washington University School of Medicine, St. Louis, MO
- Department of Pediatrics (MB, CDS), Washington University School of Medicine, St. Louis, MO
| | - Zachary A. Vesoulis
- Division of Newborn Medicine (ZAV, CM), Washington University School of Medicine, St. Louis, MO
| | - Christopher D. Smyser
- Department of Pharmacy (CP, CL, BZ, CM), St. Louis Children’s Hospital, St. Louis, MO
- Department of Neurology (MB, CDS), Washington University School of Medicine, St. Louis, MO
- Department of Pediatrics (MB, CDS), Washington University School of Medicine, St. Louis, MO
- Department of Radiology (CDS), Washington University School of Medicine, St. Louis, MO
| | - Christopher McPherson
- Division of Newborn Medicine (ZAV, CM), Washington University School of Medicine, St. Louis, MO
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