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Moraes LHA, Maropo VLB, Zoboli I, Falcão MC, de Carvalho WB. Severe irritability in a critically ill preterm infant: a case of delirium at the neonatal intensive care unit. Dement Neuropsychol 2023; 17:e20220046. [PMID: 37223840 PMCID: PMC10202332 DOI: 10.1590/1980-5764-dn-2022-0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/26/2022] [Accepted: 08/17/2022] [Indexed: 05/25/2023] Open
Abstract
Delirium is a common disorder in intensive care units, being associated with greater morbidity and mortality. However, in neonatal intensive care units, delirium is rarely diagnosed, due to the low familiarity of the neonatologist with the subject and the difficulties in the applicability of diagnostic questionnaires. This case report aimed to assess the presence of this disorder in this group of patients and identify the difficulties encountered in the diagnosis and treatment. We report the case of a premature newborn with necrotizing enterocolitis during hospitalization and underwent three surgical approaches. The newborn exhibited intense irritability, having received high doses of fentanyl, dexmedetomidine, clonidine, ketamine, phenytoin, and methadone, without the control of the symptoms. A diagnosis of delirium was then made and treatment with quetiapine was started, with a complete reversal of the symptoms. This is the first case reported in Brazil and the first describing the withdrawal of the quetiapine.
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Affiliation(s)
- Lucas Hirano Arruda Moraes
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Pediatria, Pós-Graduação em Ciências da Saúde, São Paulo SP, Brazil
| | - Vanessa Lisbethe Bezerra Maropo
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Pediatria, Residente de Neonatologia, São Paulo SP, Brazil
| | - Ivete Zoboli
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança e do Adolescente, Grupo de Dor e Cuidados Paliativos, São Paulo SP, Brazil
| | - Mário Cícero Falcão
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Pediatria, São Paulo SP, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança e do Adolescente, Centro de Terapia Intensiva Neonatal 2, São Paulo SP, Brazil
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Langman LJ, Rushton AM, Thomas D, Colbourne P, Seiden-Long I, Brun MM, Colantonio D, Jannetto PJ. Drug testing in support of the diagnosis of neonatal abstinence syndrome: The current situation. Clin Biochem 2023; 111:1-10. [PMID: 36379240 DOI: 10.1016/j.clinbiochem.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/21/2022] [Accepted: 11/07/2022] [Indexed: 11/13/2022]
Abstract
Illicit drug use during pregnancy is a concern worldwide, with many international studies describing attempted strategies to mitigate this problem. Drug misuse during pregnancy is associated with significant maternal as well as perinatal complications, which include a high incidence of stillbirths, fetal distress, neonatal abstinence syndrome (NAS) and increased neonatal mortality. Unfortunately, the identification of a drug-exposed mother or neonate is challenging. Maternal disclosure of drug use is often inaccurate, principally due to psychosocial factors including behavioral denial or the fear of the consequences resulting from such admissions. Likewise, many infants who have been exposed to drugs in utero may appear normal at birth and initially show no overt manifestations of drug effects. Thus, the identification of the drug-exposed infant requires a high index of clinical suspicion. Conversely, analytical testing is an objective means of determining drug exposure when it may be necessary to document proof of the infant's exposure to illicit drugs. The review will discuss the different matrices that are most commonly used for testing (e.g., maternal urine, neonatal urine, meconium, and umbilical cord), the strengths and limitations for each matrix, which drugs and metabolites are appropriate for testing, the various testing methods, and the advantages and disadvantages of each method.
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Affiliation(s)
- Loralie J Langman
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States.
| | - Alysha M Rushton
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Dylan Thomas
- Alberta Precision Laboratories, Department of Pathology and Laboratory Medicine, University of Alberta, Edmonton, AB, Canada
| | - Penny Colbourne
- Alberta Precision Laboratories, Department of Pathology and Laboratory Medicine, University of Alberta, Edmonton, AB, Canada
| | - Isolde Seiden-Long
- Alberta Precision Laboratories and Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, Canada
| | - Miranda M Brun
- Alberta Precision Laboratories, Department of Pathology and Laboratory Medicine, University of Alberta, Edmonton, AB, Canada
| | - David Colantonio
- Eastern Ontario Regional Laboratory Association and Department of Pathology and Laboratory Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Paul J Jannetto
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
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Czynski AJ, Laptook AR. The Time is NOW: Filling the Gaps in Treatment of Opioid-Exposed Infants: A Prospective, Pragmatic, Randomized Control Drug Trial. R I Med J (2013) 2021; 104:17-21. [PMID: 33789403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The opioid epidemic has reached into all aspects of life in the United States. The epidemic has crossed racial, economic, social, and generational barriers. This epidemic also impacts infants. Fetal exposure to opioids can produce a withdrawal effect in newborns, referred to as Neonatal Opioid Withdrawal Syndrome (NOWS). NOWS treatment lacks a standard approach, with prominent variation across the United States. Furthermore, many treatment strategies for NOWS are not evidence-based but reflect anecdotal experience. Variable approaches to NOWS treatment contribute to more extended hospital stays and greater postnatal opioid exposure. The most prolonged period of NOWS treatment occurs during the weaning phase. This paper describes the first prospective randomized control trial to address systematized weaning of opioids for infants with NOWS.
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Affiliation(s)
- Adam J Czynski
- Department of Pediatrics, Women and Infants Hospital, Brown University; COBRE on Opioids and Overdose, Rhode Island Hospital, Providence, RI
| | - Abbot R Laptook
- Department of Pediatrics, Women and Infants Hospital, Brown University, Providence, RI
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Yen E, Maron JL. Aberrant Feeding and Growth in Neonates With Prenatal Opioid Exposure: Evidence of Neuromodulation and Behavioral Changes. Front Pediatr 2021; 9:805763. [PMID: 35127598 PMCID: PMC8814597 DOI: 10.3389/fped.2021.805763] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 12/28/2021] [Indexed: 11/13/2022] Open
Abstract
Opioid use disorder (OUD) among pregnant women over the last decade has led to more than a fivefold increase in the number of neonates born with withdrawal signs known as Neonatal Abstinence Syndrome (NAS) or Neonatal Opioid Withdrawal Syndrome (NOWS). The impact of prenatal opioid exposure on these neonates remains a public health and research priority due to both its short and long-term effects on offspring. Among the adverse long-term effects associated with OUD is a metabolic syndrome with accompanying cardiovascular comorbidities. The susceptibility to metabolic diseases may begin as early as conception. Neonates born in a setting of prenatal opioid exposure are known to have aberrant early growth, e.g., lower birth weight and smaller head size, and dysregulated feeding behavior that ranges from feeding difficulty to hyperphagia which may predispose these neonates to metabolic syndrome in adulthood. However, studies on this topic are lacking. In this article, we describe the reported association between OUD and metabolic syndrome in adults, animal data linking opioid receptors with the development of diet-induced obesity, the inflammatory modulation of opioids and finally, neonatal salivary transcriptomic data from our laboratory that highlighted the sex-specific impact of opioids on the hypothalamic and reward receptors that regulate feeding behavior in opioid-exposed neonates. There is a great need for future research linking opioids with epigenetic and gene expression changes, as well as neuromodulatory effects in the developing brain, that may underlie the dysregulated feeding, growth, and long-term metabolic and cardiovascular risks for these neonates.
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Affiliation(s)
- Elizabeth Yen
- Mother Infant Research Institute, Tufts Medical Center, Boston, MA, United States.,Department of Pediatrics, Tufts University School of Medicine, Boston, MA, United States
| | - Jill L Maron
- Department of Pediatrics, Women & Infants Hospital of Rhode Island, Providence, RI, United States.,Warren Alpert Medical School of Brown University, Providence, RI, United States
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D'Abaco E. Does the addition of clonidine to opioid therapy improve outcomes in infants with Neonatal Abstinence Syndrome? J Paediatr Child Health 2021; 57:155-159. [PMID: 33493373 DOI: 10.1111/jpc.15265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 07/12/2020] [Accepted: 10/12/2020] [Indexed: 11/30/2022]
Abstract
To undertake a literature search and critical appraisal of best available evidence to answer the clinical question: Does the addition of clonidine (I) to standard treatment with an opioid (C) improve outcomes (O) in infants with Neonatal Abstinence Syndrome? A search of both comprehensive (MedLine and Embase) and pre-filtered databases (Dynamed, UpToDate and TRIP), utilising Boolean Operators to combine search terms appropriately. Three relevant studies were identified. One paper describing the outcomes of a randomised controlled trial by Agthe et al. (2009) most accurately answered the clinical question posed. This paper was critically appraised, and evidence applied to the clinical scenario. The use of clonidine as an adjunct to opioid in the management of infants with NAS reduces the total number of treatment days and dose of opioid required to control symptoms. However, there is a higher risk of rebound in symptoms post-cessation of opioid and clinicians need to account for this in their discharge planning. More large scale, multi-centre high-quality research is needed to clarify the role of clonidine in the treatment of NAS: as monotherapy versus adjunct, the optimal dose and longer-term impact on neurodevelopment.
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Affiliation(s)
- Elise D'Abaco
- Paediatric Medicine, Western Health, Joan Kirmer Women's and Children's Hospital, Melbourne, Victoria, Australia.,The University of Sydney, Faculty of Medicine and Health, Sydney, New South Wales, Australia
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6
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Affiliation(s)
- Laura J Sherman
- Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Amy M. Kilbourne, Ph.D., M.P.H., and Tami L. Mark, Ph.D., are editors of this column
| | - Mir M Ali
- Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Amy M. Kilbourne, Ph.D., M.P.H., and Tami L. Mark, Ph.D., are editors of this column
| | - Ryan Mutter
- Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Amy M. Kilbourne, Ph.D., M.P.H., and Tami L. Mark, Ph.D., are editors of this column
| | - Justine Larson
- Substance Abuse and Mental Health Services Administration, Rockville, Maryland. Amy M. Kilbourne, Ph.D., M.P.H., and Tami L. Mark, Ph.D., are editors of this column
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Wachman EM, Warden AH, Thomas Z, Thomas-Lewis JA, Shrestha H, Nikita FNU, Shaw D, Saia K, Schiff DM. Impact of psychiatric medication co-exposure on Neonatal Abstinence Syndrome severity. Drug Alcohol Depend 2018; 192:45-50. [PMID: 30205307 DOI: 10.1016/j.drugalcdep.2018.07.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/11/2018] [Accepted: 07/13/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Among opioid-exposed infants, psychiatric medication co-exposure is common. Our objective was to compare Neonatal Abstinence Syndrome (NAS) outcomes based on individual psychiatric medication co-exposures. METHODS A retrospective study of 744 opioid-exposed mother-infant dyads from a single institution was performed. Mothers on pharmacotherapy with methadone or buprenorphine at delivery were included. Data were collected on maternal demographics, psychiatric medication use, and NAS outcomes, including any medication treatment, adjunctive medication treatment, length of hospital stay (LOS), and opioid treatment days. The extent to which individual psychiatric medication and polypharmacy exposure were associated with NAS outcomes was assessed using multivariable regression. RESULTS Fifty-four percent of the mothers were on ≥1 psychiatric medication, with 32% on ≥2 or psychiatric medications (polypharmacy group). In adjusted models, polypharmacy exposure was associated with longer LOS (β = 4.31 days, 95% CI 2.55-6.06) and opioid treatment days (β = 3.98 days, 95% CI 2.24-5.72) and more treatment with adjunctive medication for NAS (aOR = 2.49, 95% CI 1.57-3.95). Benzodiazepines were associated with longer LOS (β = 4.94, 95% CI 2.86-7.03) and opioid treatment days (β = 4.86, 95% CI 2.61-6.75), and more adjunctive medication treatment (aOR = 2.57, 95% CI 1.49-4.42). Gabapentin was associated with longer LOS (β = 2.79, 95% CI 0.54-5.03), more NAS medication treatment (aOR = 2.96, 95% CI 1.18-7.42) including more adjunctive medications (aOR = 1.92, 95% CI 1.05-3.53). CONCLUSION For infants of mothers with OUD who are also on concurrent psychiatric medications, polypharmacy was associated with worse NAS severity. When medically indicated, limiting use of multiple psychiatric medications, particularly benzodiazepines and gabapentin, during pregnancy should be considered to improve NAS outcomes.
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Affiliation(s)
- Elisha M Wachman
- Department of Pediatrics, Boston Medical Center, 771 Albany Street, Boston, MA, 02118, USA.
| | - A Hutcheson Warden
- Department of Obstetrics and Gynecology, Boston Medical Center, 771 Albany Street, Boston, MA, 02118, USA.
| | - Zoe Thomas
- University of Massachusetts, 300 Massachusetts Ave, Amherst, MA, 01003, USA.
| | - Jo Ann Thomas-Lewis
- Boston University School of Medicine, 72 East Concord Street, Boston, MA, 02118, USA.
| | - Hira Shrestha
- Department of Pediatrics, Boston Medical Center, 771 Albany Street, Boston, MA, 02118, USA.
| | - F N U Nikita
- Boston University School of Public Health, 715 Albany Street, Boston, MA, 021178, USA.
| | - Daniel Shaw
- Department of Psychiatry, Boston Medical Center, 771 Albany Street, Boston, MA, 02118, USA.
| | - Kelley Saia
- Department of Obstetrics and Gynecology, Boston Medical Center, 771 Albany Street, Boston, MA, 02118, USA.
| | - Davida M Schiff
- Division of General Academic Pediatrics, Mass General Hospital for Children, 55 Fruit Street, Boston, MA, 02114, USA.
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Whittaker A, Chandler A, Cunningham-Burley S, Midgley P, Elliott L, Cooper S. Problematisation and regulation: Bodies, risk, and recovery within the context of Neonatal Abstinence Syndrome. Int J Drug Policy 2019; 68:139-46. [PMID: 30025899 DOI: 10.1016/j.drugpo.2018.06.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 05/01/2018] [Accepted: 06/11/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Neonatal Abstinence Syndrome (NAS) is an anticipated effect of maternal drug use during pregnancy. Yet it remains a contested area of policy and practice. In this paper, we contribute to ongoing debates about the way NAS is understood and responded to, through different treatment regimes, or logics of care. Our analysis examines the role of risk and recovery discourses, and the way in which the bodies of women and babies are conceptualised within these. METHODS Qualitative interviews with 16 parents (9 mothers, 7 fathers) and four focus groups with 27 health and social care professionals based in Scotland. All the mothers were prescribed opioid replacement therapy and parents were interviewed after their baby was born. Data collection explored understandings about the causes and consequences of NAS and experiences of preparing for, and caring for, a baby with NAS. Data were analysed using a narrative and discursive approach. RESULTS Parent and professional accounts simultaneously upheld and subverted logics of care which govern maternal drug use and the assessment and care of mother and baby. Despite acknowledging the unpredictability of NAS symptoms and the inability of the women who are opioid-dependent to prevent NAS, logics of care centred on 'proving' risk and recovery. Strategies appealed to the need for caution, intervening and control, and obscured alternative logics of care that focus on improving support for mother-infant dyads and the family as a whole. CONCLUSION Differing notions of risk and recovery that govern maternal drug use, child welfare and family life both compel and trouble all logics of care. The contentious nature of NAS reflects wider socio-political and moral agendas that ultimately have little to do with meeting the needs of mothers and babies. Fundamental changes in the principles, quality and delivery of care could improve outcomes for families affected by NAS.
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Gomez Pomar E, Finnegan LP, Devlin L, Bada H, Concina VA, Ibonia KT, Westgate PM. Simplification of the Finnegan Neonatal Abstinence Scoring System: retrospective study of two institutions in the USA. BMJ Open 2017; 7:e016176. [PMID: 28963285 PMCID: PMC5623549 DOI: 10.1136/bmjopen-2017-016176] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To develop a simplified Finnegan Neonatal Abstinence Scoring System (sFNAS) that will highly correlate with scores ≥8 and ≥12 in infants being assessed with the FNAS. DESIGN, SETTING AND PARTICIPANTS This is a retrospective analysis involving 367 patients admitted to two level IV neonatal intensive care units with a total of 40 294 observations. Inclusion criteria included neonates with gestational age ≥37 0/7 weeks, who are being assessed for neonatal abstinence syndrome (NAS) using the FNAS. Infants with a gestational age <37 weeks were excluded. METHODS A linear regression model based on the original FNAS data from one institution was developed to determine optimal values for each item in the sFNAS. A backward elimination approach was used, removing the items that contributed least to the Pearson's correlation. The sFNAS was then cross-validated with data from a second institution. RESULTS Pearson's correlation between the proposed sFNAS and the FNAS was 0.914. The optimal treatment cut-off values for the sFNAS were 6 and 10 to predict FNAS scores ≥8 and ≥12, respectively. The sensitivity and specificity of these cut-off values to detect FNAS scores ≥8 and ≥12 were 0.888 and 0.883 for a cut-off of 6, and 0.637 and 0.992 for a cut-off of 10, respectively. The sFNAS cross-validation resulted in a Pearson's correlation of 0.908, sensitivity and specificity of 0.860 and 0.873 for a cut-off of 6, and 0.525 and 0.986 for a cut-off of 10, respectively. CONCLUSION The sFNAS has a high statistical correlation with the FNAS, and it is cross-validated for the assessment of infants with NAS. It has excellent specificity and negative predictive value for identifying infants with FNAS scores ≥8 and ≥12.
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Affiliation(s)
- Enrique Gomez Pomar
- Department of Pediatrics, Division of Neonatology, University of Kentucky, Frankfort, Kentucky, USA
| | | | - Lori Devlin
- Department of Pediatrics, Division of Neonatology, University of Louisville, Louisville, Kentucky, USA
| | - Henrietta Bada
- Department of Pediatrics, Division of Neonatology, University of Kentucky, Frankfort, Kentucky, USA
| | - Vanessa A Concina
- Department of Pediatrics, Division of Neonatology, University of Kentucky, Frankfort, Kentucky, USA
| | - Katrina T Ibonia
- Department of Pediatrics, Division of Neonatology, University of Kentucky, Frankfort, Kentucky, USA
| | - Philip M Westgate
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, Kentucky, USA
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Schiff DM, Zuckerman B, Wachman EM, Bair-Merritt M. Trainees' knowledge, attitudes, and practices towards caring for the substance-exposed mother-infant dyad. Subst Abus 2017; 38:414-421. [PMID: 28715290 DOI: 10.1080/08897077.2017.1356423] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND As rates of substance use disorder during pregnancy rise, pediatric trainees are increasingly caring for infants with neonatal abstinence syndrome (NAS). This study evaluated the knowledge, attitudes, and practices of trainees caring for substance-exposed newborns and their families, comparing differences by level and type of training, and personal experience with addiction or trauma. METHODS A cross-sectional survey of medical students and pediatric, medicine/pediatric, and family medicine residents in 2015-2106. Measures included knowledge about NAS, attitudes towards mothers who use drugs, and practices around discussing addiction and trauma with families. Descriptive and bivariate analyses were conducted. RESULTS The overall response rate was 70%, with 229 trainees included in the final sample (99 students, 130 residents). Fifty percent of trainees endorsed personal experience with addiction, 50% with trauma, and 35% with both addiction and trauma. Increasing years of pediatric training was associated with greater comfort in managing symptoms of NAS but decreased comfort discussing addiction and trauma. Family medicine and medicine/pediatric residents were more comfortable discussing addiction and trauma than categorical pediatric residents (P < .01). Twenty-two percent of trainees felt confident that mothers would disclose illicit drug use, 39% felt that they would actively care for their infants with NAS, and 43% felt that mothers would not make unreasonable demands. Personal experience with addiction or trauma did not significantly impact trainees' attitudes towards women with substance use disorder. CONCLUSIONS Trainees may benefit from educational interventions focused on developing a 2-generational model of trauma-informed care to improve attitudes and ultimately the care of substance-exposed infants and their families.
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Affiliation(s)
- Davida M Schiff
- a Department of Pediatrics , Boston Medical Center , Boston , Massachusetts , USA.,b Boston University School of Medicine , Boston , Massachusetts , USA
| | - Barry Zuckerman
- a Department of Pediatrics , Boston Medical Center , Boston , Massachusetts , USA.,b Boston University School of Medicine , Boston , Massachusetts , USA
| | - Elisha M Wachman
- a Department of Pediatrics , Boston Medical Center , Boston , Massachusetts , USA.,b Boston University School of Medicine , Boston , Massachusetts , USA.,c Division of Neonatology , Boston Medical Center , Boston , Massachusetts , USA
| | - Megan Bair-Merritt
- a Department of Pediatrics , Boston Medical Center , Boston , Massachusetts , USA.,b Boston University School of Medicine , Boston , Massachusetts , USA
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MacVicar S, Humphrey T, Forbes-McKay KE. Breastfeeding support and opiate dependence: A think aloud study. Midwifery 2017; 50:239-245. [PMID: 28494389 DOI: 10.1016/j.midw.2017.04.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 04/11/2017] [Accepted: 04/25/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVE international guidelines recommend the promotion and protection of breastfeeding for the substance exposed mother and baby. Yet few studies have explored the facilitators, moderators and barriers to successful breastfeeding for women enrolled on opiate maintenance treatment, or suggested targeted support strategies. The aim of this study was to explore the views of women with opiate dependence on proposed elements for inclusion in a breastfeeding support intervention. DESIGN a qualitative study using think aloud technique. SETTING tertiary maternity hospital in the North-East of Scotland. Interviews conducted between November 2013 and March 2014. PARTICIPANTS 6 opiate dependent women within 6 months of giving birth. Participants were enrolled on opiate medication treatment during their pregnancy, had initiated breastfeeding and accessed in-hospital breastfeeding support. FINDINGS an intervention founded on practical, informational and environmental elements was endorsed as supportive of continued breastfeeding of an infant at risk of Neonatal Abstinence Syndrome. Opiate dependent women were more receptive to strategies promoting a person-centered approach that were specific to their individualized infant feeding needs and delivered within an emotionally supportive environment. Barriers to the acceptability of breastfeeding advice included discouraging, prescriptive and judgemental healthcare actions and attitudes. KEY CONCLUSIONS there are distinct facilitators, modifiers and barriers to breastfeeding within the context of opiate exposure. Using this awareness to underpin the key features of the design should enhance maternal receptiveness, acceptability and usability of the support intervention. IMPLICATIONS FOR PRACTICE additional and tailored support interventions are required to meet the specific needs of breastfeeding an infant experiencing opiate withdrawal. The elimination of disempowering institutional actions and attitudes is imperative if a conducive environment in which opiate dependent women feel supported is to be achieved.
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Affiliation(s)
- Sonya MacVicar
- Institute of Health and Wellbeing, Robert Gordon University, Garthdee Road, Aberdeen AB10 7QB, United Kingdom; School of Health and Social Care, Edinburgh Napier University, Sighthill Court, Edinburgh EH11 4BN, United Kingdom.
| | - Tracy Humphrey
- School of Health and Social Care, Edinburgh Napier University, Sighthill Court, Edinburgh EH11 4BN, United Kingdom.
| | - Katrina E Forbes-McKay
- School of Social Studies, Robert Gordon University, Garthdee Road, Aberdeen AB10 7QB, United Kingdom.
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12
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Ng CM, Dombrowsky E, Lin H, Erlich ME, Moody DE, Barrett JS, Kraft WK. Population Pharmacokinetic Model of Sublingual Buprenorphine in Neonatal Abstinence Syndrome. Pharmacotherapy 2015; 35:670-80. [PMID: 26172282 DOI: 10.1002/phar.1610] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Neonatal abstinence syndrome (NAS)--a clinical entity of infants from in utero exposure to psychoactive xenobiotic and buprenorphine--has been successfully used to treat NAS. However, nothing is known about the pharmacokinetics (PK) of buprenorphine in neonates with NAS. To our knowledge, this is the first study to investigate the population pharmacokinetic of sublingual buprenorphine in neonates with NAS. DESIGN A retrospective population PK analysis of: (1) neonates with NAS treated with sublingual buprenorphine in randomized, double blinded clinical study and (2) data from healthy adults from a previously published pharmacokinetic study. SETTING Neonatal intensive care unit and general clinical research unit. PATIENTS Twenty-four neonates with NAS and five healthy adults. INTERVENTIONS All participants received sublingual buprenorphine per study protocol. MEASUREMENTS AND MAIN RESULTS A total of 303 PK data from 29 neonates and adults were used for model development. A population pharmacokinetic analysis was conducted using a first order conditional estimation with interaction in the NONMEM software program. A two-compartment linear PK model with first-order absorption process best described the pharmacokinetics of sublingual buprenorphine in neonates. The apparent clearance (CL) of buprenorphine was linearly related to body weight and matured with increasing age via two distinct saturated pathways. A typical neonate with NAS (body weight, 2.9 kg; postnatal age; 5.4 days) had a CL of 3.5 L/kg/hour and elimination half-life of 11 hours. Phenobarbital did not affect the clearance of buprenorphine compared to neonates of similar age and weight. CONCLUSIONS This is the first study to investigate the population PK of sublingual buprenorphine in neonatal NAS. To our knowledge, this is also the first report to describe the age-dependent changes of buprenorphine PK in this patient population. No buprenorphine dose adjustment is needed for neonates with NAS treated with buprenorphine and concurrent phenobarbital.
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Affiliation(s)
- Chee M Ng
- Clinical Pharmacology and Therapeutics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Erin Dombrowsky
- Clinical Pharmacology and Therapeutics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Hopi Lin
- Clinical Pharmacology and Therapeutics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michelle E Erlich
- Department of Pediatrics and Neurology, Mt. Sinai School of Medicine, New York, New York
| | - David E Moody
- Center of Human Toxicology, Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, Utah
| | - Jeffrey S Barrett
- Clinical Pharmacology and Therapeutics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Walter K Kraft
- Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, Pennsylvania
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Abstract
Opioid dependent pregnant and post-partum women and their infants are a complex and vulnerable population requiring individualized, comprehensive and multidisciplinary treatment. Though methadone maintenance in the setting of comprehensive service provision during pregnancy significantly improves pregnancy outcomes for opioid dependent women, its use has implications for the infant, most notably the Neonatal Abstinence Syndrome (NAS). NAS is comprised of physiologic signs and behaviors that indicate a dysfunctional regulation of the central and autonomic nervous systems, and is variable in its expression in affected infants. The disorganized rather than adaptive behaviors displayed by each infant undergoing the effects of in-utero opioid exposure may impair basic functions such as feeding, sleeping, and the ability to be alert and communicate clear cues to caregivers. Understanding and responding to neurobehavioral dysfunction of the newborn may help to promote the infant's self-organization and self-regulating abilities. However, the substance abusing mother's physical and psychological wellbeing may be debilitated in the perinatal period, and her ability to recognize and respond to the newborn's cues may be limited. A multi-tiered comprehensive assessment and intervention of the methadone-maintained mother, her child, and the mother/infant dyad can improve early maternal nurturing interactions, a crucial component of early infant development, particularly in this vulnerable population. The purpose of this article is to review the contribution of maternal opioid dependency to the difficulties experienced by the mother-infant dyad and their treatment providers in the postnatal period, and the non-pharmacological treatment of the infants with suggestions for practical measures with emphasis on the treatment of the mother and baby as an interactional dyad.
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