1
|
Jamali Z, Molaei-Farsangi MH, Ahmadipour H, Bahmanbijari B, Sabzevari F, Parizi ZD. Comparison of the effect of phenobarbital & levetiracetam in the treatment of neonatal abstinence syndrome (NAS) as adjuvant treatment in neonates admitted to the neonatal intensive care unit: a randomized clinical trial. BMC Pregnancy Childbirth 2024; 24:242. [PMID: 38580935 PMCID: PMC10996075 DOI: 10.1186/s12884-024-06433-y] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 03/18/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Infants who are born from mothers with substance use disorder might suffer from neonatal abstinence syndrome (NAS) and need treatment with medicines. One of these medicines is phenobarbital, which may cause side effects in long-term consumption. Alternative drugs can be used to reduce these side effects. This study seeks the comparison of the effects of phenobarbital & levetiracetam as adjuvant therapy in neonatal abstinence syndrome. METHODS This randomized clinical trial was performed in one year from May 2021 until May 2022. The neonates who were born from mothers with substance use disorder and had neonatal abstinence syndrome in Afzalipoor Hospital of Kerman were studied. The treatment started with morphine initially and every four hours the infants were checked. The infants who were diagnosed with uncontrolled symptoms After obtaining informed consent from the parents were randomly divided into two groups and treated with secondary drugs, either phenobarbital or levetiracetam. RESULTS Based on the obtained results, it was clear that there was no significant difference between the hospitalization time of the two infant groups under therapy (phenobarbital: 18.59 days versus Levetiracetam 18.24 days) (P-value = 0.512). Also, there was no significant difference between both groups in terms of the frequency of re-hospitalization during the first week after discharge, the occurrence of complications, and third treatment line prescription (P-value = 0.644). CONCLUSIONS Based on the obtained results, like hospitalization duration time (P-value = 0.512) it seems that levetiracetam can be used to substitute phenobarbital in treating neonatal abstinence syndrome. TRIAL REGISTRATION The current study has been registered in the Iran registry of clinical trials website (fa.irct.ir) on the date 25/2/2022 with registration no. IRCT20211218053444N2.
Collapse
Affiliation(s)
- Zahra Jamali
- Department of Pediatrics, School of Medicine, Afzalipour Hospital, Kerman University of Medical Sciences, Kerman, Iran
| | - Mohammad Hosein Molaei-Farsangi
- Department of Pediatrics, School of Medicine; Clinical Research Development Unit, Afzalipour Hospital, Kerman University of Medical Sciences, Kerman, Iran.
| | - Habibeh Ahmadipour
- Department of Social Medicine, School of Medicine, Social Determinants of Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Bahareh Bahmanbijari
- Department of Pediatrics, School of Medicine, Afzalipour Hospital, Kerman University of Medical Sciences, Kerman, Iran
| | - Fatemeh Sabzevari
- Department of Pediatrics, School of Medicine, Afzalipour Hospital, Kerman University of Medical Sciences, Kerman, Iran
| | - Zahra Daei Parizi
- Department of Pediatrics, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| |
Collapse
|
2
|
Morales P, Santiago L, Rosario J, Garcia-Fragoso L, Duconge J, Perez N, Santiago D. Neonatal Abstinence Syndrome and Corresponding Pharmacotherapy Approaches from 2 University-affiliated Neonatal Intensive Care Units in Puerto Rico (2018-2020). P R Health Sci J 2024; 43:25-31. [PMID: 38512758 PMCID: PMC11061712] [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] [Grants] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
OBJECTIVE Neonatal abstinence syndrome (NAS) is a set of drug withdrawal symptoms suffered by neonates exposed to drugs in utero. Several studies have widely described NAS incidence and treatment approach; however, little is known regarding the incidence and manifestations of this disease in Puerto Rico (PR). The principal aim of this study was to describe NAS incidence in the neonatal units of hospitals affiliated with the University of PR in terms of occurrence, clinical manifestations, and treatment approaches. METHODS Our study evaluated the medical records of NAS babies diagnosed from 2018 through 2020 at 2 hospitals affiliated with the University of PR Medical Sciences Campus. Descriptive and inferential statistics were employed to analyze trends. RESULTS We identified 12 neonates diagnosed with NAS, 5 with low birthweights (<2500 g); for a NAS incidence of 2 cases per 1000 admitted for the 3 years of recollected data. The urine toxicology results revealed that 9 had experienced intrauterine polydrug exposure. Phenobarbital loading dose were determined on the day of diagnosis (indicated by Finnegan score). The first manifestation of NAS symptoms varied: 8 neonates showed symptoms within 48 hours after birth, whereas 4 had withdrawal symptoms within 72-120 hours of their births. Differences between dosing practices and guidelines were observed, ranging from a 0.69% to a 25% difference during treatment initiation. CONCLUSION Further research on the incidence of NAS in PR (national level) is needed for a deeper understanding that we hope will lead to the development of enhanced treatment protocols in PR.
Collapse
Affiliation(s)
- Pamela Morales
- School of Pharmacy, University of Puerto Rico, Medical Sciences Campus
| | | | | | - Lourdes Garcia-Fragoso
- Neonatology section, Department of Pediatrics, School of Medicine, University of Puerto Rico
| | - Jorge Duconge
- School of Pharmacy, University of Puerto Rico, Medical Sciences Campus
| | - Naidy Perez
- The Alliance for Clinical and Translational Research
| | - Darlene Santiago
- School of Pharmacy, University of Puerto Rico, Medical Sciences Campus
| |
Collapse
|
3
|
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: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| | | |
Collapse
|
4
|
Ikeri K, Anderson A, Eyal F, Whitehurst R. Neonatal Opioid Withdrawal Syndrome Following Prenatal Use of Supplements Containing Tianeptine. Pediatrics 2024; 153:e2023062382. [PMID: 38213293 DOI: 10.1542/peds.2023-062382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2023] [Indexed: 01/13/2024] Open
Abstract
Tianeptine is an opioid receptor agonist that is prescribed as an antidepressant in many countries. In the United States, tianeptine is not approved for medical use because of its potential for abuse and addiction. Nonetheless, products containing tianeptine are easily obtainable and are marketed as dietary supplements. There are increasing reports of adverse effects and fatal toxicities resulting from tianeptine use among adolescents and adults. This emerging public health threat could escalate the opioid epidemic and drive increased newborn perinatal exposure. The impact of in utero exposure to tianeptine has not been studied, and to our knowledge, the authors of only 1 report have documented possible neonatal effects. Here, we describe a case of chronic prenatal exposure to tianeptine in the setting of maternal dependence on dietary supplements. This infant developed signs of severe withdrawal shortly after birth that were refractory to treatment with oral phenobarbital but responded to subsequent oral morphine therapy. On further questioning, the mother revealed the use of a tianeptine-containing dietary supplement. We did not perform confirmatory toxicology testing because tianeptine is not assayed by usual urine drug screening tests. For infants with clinical signs of opioid withdrawal without known etiology, we suggest that the maternal interview should inquire about the use of neurotropic over-the-counter drugs.
Collapse
Affiliation(s)
- Kelechi Ikeri
- Division of Neonatology, University of South Alabama Children's and Women's Hospital, Mobile, Alabama
| | - Alexandria Anderson
- Division of Neonatology, University of South Alabama Children's and Women's Hospital, Mobile, Alabama
| | - Fabien Eyal
- Division of Neonatology, University of South Alabama Children's and Women's Hospital, Mobile, Alabama
| | - Richard Whitehurst
- Division of Neonatology, University of South Alabama Children's and Women's Hospital, Mobile, Alabama
| |
Collapse
|
5
|
West KD, Ali MM, Blanco M, Natzke B, Nguyen L. Prenatal Substance Exposure and Neonatal Abstinence Syndrome: State Estimates from the 2016-2020 Transformed Medicaid Statistical Information System. Matern Child Health J 2023; 27:14-22. [PMID: 37219692 PMCID: PMC10204012 DOI: 10.1007/s10995-023-03670-z] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 05/24/2023]
Abstract
INTRODUCTION Estimating Neonatal Abstinence Syndrome (NAS) and prenatal substance exposure rates in Medicaid can help target program efforts to improve access to services. METHODS The data for this study was extracted from the 2016-2020 Transformed Medicaid Statistical Information System (T-MSIS) Analytic Files (TAF) Research Identifiable Files (RIF) and included infants born between January 1, 2016 and December 31, 2020 with a either a NAS diagnosis or prenatal substance exposure. RESULTS Between 2016 and 2020, the estimated national rate of NAS experienced a 18% decline, while the estimated national rate of prenatal substance exposure experienced a 3.6% increase. At the state level in 2020, the NAS rate ranged from 3.2 per 1000 births (Hawaii) to 68.0 per 1000 births (West Virginia). Between 2016 and 2020, 28 states experienced a decline in NAS births and 20 states had an increase in NAS rates. In 2020, the lowest prenatal substance exposure rate was observed in New Jersey (9.9 per 1000 births) and the highest in West Virginia (88.1 per 1000 births). Between 2016 and 2020, 38 states experienced an increase in the rate of prenatal substance exposure and 10 states experienced a decline. DISCUSSION Estimated rate of NAS has declined nationally, but rate of prenatal substance exposure has increased, with considerable state-level variation. The reported increase in prenatal substance exposure in the majority of US states (38) suggest that substances other than opioids are influencing this trend. Medicaid-led initiatives can be used to identify women with substance use and connect them to services.
Collapse
Affiliation(s)
- Kristina D West
- Office of the Assistant Secretary for Planning & Evaluation, U.S. Department of Health and Human Services, 200 Independence Ave SW, Washington, DC, 20543, USA.
| | - Mir M Ali
- Office of the Assistant Secretary for Planning & Evaluation, U.S. Department of Health and Human Services, 200 Independence Ave SW, Washington, DC, 20543, USA
| | - Martin Blanco
- Office of the Assistant Secretary for Planning & Evaluation, U.S. Department of Health and Human Services, 200 Independence Ave SW, Washington, DC, 20543, USA
| | - Brenda Natzke
- Mathematica, 1100 First Street, NE, 12th Floor, Washington, DC, 20002-4221, USA
| | - Linda Nguyen
- Mathematica, 1100 First Street, NE, 12th Floor, Washington, DC, 20002-4221, USA
| |
Collapse
|
6
|
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: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
7
|
Rana D, McLeod AR, Gaston PK, Hill DM, Pourcyrous M. Assessing Neonatal Opioid Withdrawal Syndrome Severity as a Function of Maternal Buprenorphine Dose and Umbilical Cord Tissue Concentrations. Ann Pharmacother 2023; 57:892-898. [PMID: 36321504 DOI: 10.1177/10600280221134643] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Infants born to mothers with opioid use disorder (OUD) and prenatally treated with buprenorphine have a significantly lower incidence of neonatal opioid withdrawal syndrome (NOWS), its treatment duration, and hospital length of stay compared with methadone. However, risk of NOWS remains and clinicians continue to lack an objective methodology to predict NOWS severity among these infants. OBJECTIVE The purpose of this study was to assess the relationship between buprenorphine exposure, umbilical cord tissue (UCT) concentrations, and NOWS development and severity. METHODS A single-center retrospective observational cohort study from March 2018 through June 2020 of newborns exposed to buprenorphine in utero. Associations between quantified buprenorphine exposure, neonatal UCT concentrations, NOWS diagnosis, and severity were made using regression analyses. RESULTS A total of 24 mothers and 25 neonates were included. Length of maternal buprenorphine therapy (months) positively correlated to norbuprenorphine (r2 = 0.234, P = 0.019) and buprenorphine + norbuprenorphine UCT concentrations (r2 = 0.203, P = 0.031). A positive relationship was seen between active metabolite concentrations and cumulative morphine dose (mg/kg) for treatment of severe NOWS (r2 = 0.471, P = 0.007). A 0.36 ng/g buprenorphine + norbuprenorphine UCT (CI = 0.002-0.72, P = 0.049) equated in a 1-point increase in modified peak Finnegan score. CONCLUSION AND RELEVANCE Buprenorphine and norbuprenorphine UCT concentrations can allow for quantification of in utero fetal exposure and demonstrate an association with a longer duration of exposure with the severity and treatment of NOWS in exposed infants.
Collapse
Affiliation(s)
- Divya Rana
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Allison R McLeod
- Department of Clinical Pharmacy, Regional One Health, Memphis, TN, USA
| | - Piyamas K Gaston
- Department of Clinical Pharmacy, Regional One Health, Memphis, TN, USA
| | - David M Hill
- Department of Clinical Pharmacy, Regional One Health, Memphis, TN, USA
| | - Massroor Pourcyrous
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, TN, USA
| |
Collapse
|
8
|
Siegel MR, Cohen SJ, Koenigs K, Woods GT, Schwartz LN, Sarathy L, Chou JH, Terplan M, Wilens T, Ecker JL, Bernstein SN, Schiff DM. Assessing the clinical utility of toxicology testing in the peripartum period. Am J Obstet Gynecol MFM 2023; 5:100963. [PMID: 37030508 DOI: 10.1016/j.ajogmf.2023.100963] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/30/2023] [Accepted: 03/31/2023] [Indexed: 04/10/2023]
Abstract
BACKGROUND Toxicology testing is frequently used as a means of gathering objective data about substance use in pregnancy, but little is known about the clinical utility of testing in the peripartum setting. OBJECTIVE This study aimed to characterize the utility of obtaining maternal-neonatal dyad toxicology testing at the time of delivery. STUDY DESIGN We performed a retrospective chart review of all deliveries in a single healthcare system in Massachusetts between 2016 and 2020, and identified deliveries with either maternal or neonatal toxicology testing at delivery. An unexpected result was defined as a positive test for a nonprescribed substance that was not known on the basis of clinical history, self-report, or previous toxicology testing within a week of delivery, excluding results for cannabis. We evaluated the characteristics of maternal-infant dyads with unexpected positive results, unexpected positive results by rationale for testing, changes in clinical management after an unexpected positive test, and maternal outcomes in the year after delivery using descriptive statistics. RESULTS Of the 2036 maternal-infant dyads with toxicology tests performed during the study period, there were 80 (3.9%) with an unexpected positive result. Diagnosis of substance use disorder with active use in the last 2 years was the clinical rationale for testing that yielded the greatest number of unexpected positive results (10.7% of total tests ordered for this rationale). Inadequate prenatal care (5.8%), maternal use of medication for opioid use disorder (3.8%), maternal medical indications such as hypertension or placental abruption (2.3%), history of substance use disorder in remission (1.7%), or maternal cannabis use (1.6%) yielded lower rates of unexpected results compared with a recent substance use disorder (within the last 2 years). Solely on the basis of findings from unexpected test results, 42% of dyads were referred to child protective services, 30% of dyads had no documentation of maternal counseling during delivery hospitalization, and 31% did not receive breastfeeding counseling after an unexpected test; 22.8% had monitoring for neonatal opioid withdrawal syndrome. Postpartum, 26 (32.5%) were referred to substance use disorder treatment, 31 (38.8%) attended a postpartum mental health visit, and only 26 (32.5%) attended a postpartum visit. Fifteen individuals (18.8%) were readmitted in the year after delivery, all for substance-related medical complications. CONCLUSION Unexpected positive toxicology results at delivery were uncommon, particularly when tests were sent for frequently used clinical rationales for testing, suggesting a need to revisit guidelines surrounding appropriateness of indications for toxicology testing. The poor maternal outcomes in this cohort highlight a missed opportunity for maternal connection to counseling and treatment in the peripartum period.
Collapse
Affiliation(s)
- Molly R Siegel
- Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston, MA (Dr Siegel, Dr Koenigs, Dr Woods, Dr Ecker, and Dr Bernstein).
| | - Samuel J Cohen
- Department of Pediatrics, Boston Medical Center, Boston, MA (Dr Cohen)
| | - Kathleen Koenigs
- Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston, MA (Dr Siegel, Dr Koenigs, Dr Woods, Dr Ecker, and Dr Bernstein)
| | - Gregory T Woods
- Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston, MA (Dr Siegel, Dr Koenigs, Dr Woods, Dr Ecker, and Dr Bernstein)
| | | | - Leela Sarathy
- Division of Newborn Medicine, Massachusetts General Hospital for Children, Boston, MA (Dr Sarathy and Dr Chou)
| | - Joseph H Chou
- Division of Newborn Medicine, Massachusetts General Hospital for Children, Boston, MA (Dr Sarathy and Dr Chou)
| | | | - Timothy Wilens
- Division of Child and Adolescent Psychiatry, Massachusetts General Hospital, Boston, MA (Dr Wilens)
| | - Jeffrey L Ecker
- Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston, MA (Dr Siegel, Dr Koenigs, Dr Woods, Dr Ecker, and Dr Bernstein)
| | - Sarah N Bernstein
- Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston, MA (Dr Siegel, Dr Koenigs, Dr Woods, Dr Ecker, and Dr Bernstein)
| | - Davida M Schiff
- Division of General Academic Pediatrics, Massachusetts General Hospital for Children, Boston, MA (Dr Schiff)
| |
Collapse
|
9
|
Heyward A, Minich N, Hoffman AC, Hibbs AM, Zhao L, Crowley M. Characteristics and outcomes of neonatal opioid withdrawal syndrome in preterm infants: a retrospective cohort study in the current era. J Perinatol 2023; 43:909-915. [PMID: 37188773 DOI: 10.1038/s41372-023-01672-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 12/15/2022] [Accepted: 01/05/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVE Compare Neonatal Opioid Withdrawal Syndrome (NOWS) in preterm and term infants. STUDY DESIGN Single center, retrospective chart review of all in-utero opioid exposed infants born between 2014 and 2019. Withdrawal symptoms were assessed using Modified Finnegan Assessment Tool. RESULTS Thirteen preterm (PT), 72 late preterm (LPT), and 178 term infants were included. Preterm and LPT compared to term infants had lower peak Finnegan scores (9/9 vs. 12) and received less pharmacologic treatment (23.1/44.4 vs. 66.3%). Similar onset, peak symptoms, and treatment duration was observed in LPT and term infants. CONCLUSIONS Preterm and LPT infants have lower Finnegan scores and require less pharmacologic therapy for NOWS. It is unclear if this is because our current assessment tool does not capture their symptoms or if they truly have less withdrawal. Onset of NOWS is similar in LPT and term infant, thus LPT infants do not require prolonged hospital monitoring for NOWS.
Collapse
Affiliation(s)
- Alicia Heyward
- Division of Neonatology, University Hospitals Rainbow Babies & Children's Hospital, Cleveland, OH, USA.
- Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - Nori Minich
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
- Department of Pediatrics, University Hospitals Rainbow Babies & Children's Hospital, Cleveland, OH, USA
| | - Adriana C Hoffman
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
- Department of Pediatrics, University Hospitals Rainbow Babies & Children's Hospital, Cleveland, OH, USA
| | - Anna Maria Hibbs
- Division of Neonatology, University Hospitals Rainbow Babies & Children's Hospital, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Lulu Zhao
- Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Moira Crowley
- Division of Neonatology, University Hospitals Rainbow Babies & Children's Hospital, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| |
Collapse
|
10
|
Hussaini KS, Yocher G. Adverse Maternal Experiences and Neonatal Abstinence Syndrome. Matern Child Health J 2023; 27:497-507. [PMID: 36592279 PMCID: PMC10949090 DOI: 10.1007/s10995-022-03577-1] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2022] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To propose a measure for adverse maternal experiences (AMEs) and examine if AMEs are independently associated with delivery of a neonatal abstinence syndrome (NAS) diagnosed infant. METHODS Using the Pregnancy Risk Assessment Monitoring System (PRAMS) stressful life events questions, we constructed a composite measure of AMEs. We conducted a retrospective analysis of linked Birth Certificate Data, Hospital Discharge Data and PRAMS data for 2012-2018 using the composite measure. Our analytic sample included 6358 singleton deliveries. We calculated prevalence of NAS and AMEs and prevalence odds ratio (POR) for delivery of an NAS-diagnosed infant adjusting for maternal sociodemographic characteristics, pre-pregnancy depression, prescription medicine 12 months prior to pregnancy, and smoking during pregnancy. RESULTS The overall prevalence of NAS in Delaware during 2012-2018 was 2.2% (95% CI 1.8-2.6); 9.5% (95% CI 8.7-10.2) of women reported AMEs. After adjustment, women with AMEs had 1.1 times greater odds (aPOR 2.1; 95% CI 1.3-3.3) to deliver a NAS-diagnosed infant as compared with women without AMEs. CONCLUSIONS Although the cross-sectional nature of the study limits drawing any causal inferences, there are co-occurring factors that support plausibility of an association between AMEs and delivering NAS-diagnosed infants. Addressing AMEs, mental health and substance use screening and treatment as part of preconception and prenatal care may mitigate risks.
Collapse
Affiliation(s)
- Khaleel S Hussaini
- Division of Reproductive Health, Field Support Branch, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, Atlanta, GA, USA.
- Division of Public Health, Delaware Department of Health and Social Services, 1351 W. North Street, Dover, DE, 19904, USA.
| | - George Yocher
- Division of Public Health, Delaware Department of Health and Social Services, 1351 W. North Street, Dover, DE, 19904, USA
| |
Collapse
|
11
|
Abstract
Neonatal abstinence syndrome (NAS) is a significant public health problem in the United States. The most commonly used tool to assess and treat infants with NAS is the Finnegan Neonatal Abstinence Scoring System (FNASS). The more recently developed Eat, Sleep, Console (ESC) method simplifies assessment of NAS. Current research suggests promising outcomes with the ESC method in areas such as length of hospital stay (LOS) and amount of medication needed to treat NAS. A literature review was conducted to answer the following question: In newborn infants with NAS born at 36 weeks of gestation or older, does the ESC method reduce the use of medication and LOS when compared with the FNASS? All of the studies reporting on LOS and medication usage rates reported a decrease in both when moving to the ESC method from FNASS.
Collapse
|
12
|
Brocato B, Lewis D, Eyal F, Baker S, Armistead C, Kaye AD, Cornett EM, Whitehurst RM. The Impact of a Prenatal Education Program for Opioid-Dependent Mothers on Breastfeeding Rates of Infants at Risk for Neonatal Abstinence Syndrome. Adv Ther 2022; 39:3104-3111. [PMID: 35522394 DOI: 10.1007/s12325-022-02146-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 04/08/2021] [Accepted: 10/28/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION This study aimed to determine the effect of a prenatal education program for opioid-dependent women on breastfeeding frequency, newborn hospital length of stay, and cost of care for neonates at risk of developing neonatal abstinence syndrome. METHODS From January 1, 2015 to January 1, 2020, opioid-dependent obstetric patients were educated on non-pharmacological preventative measures for neonatal abstinence syndrome (NAS), with focused counseling on breastfeeding. Data were collected and compared to a control group of opioid-dependent pregnant women who received standard care before initiation of the education program. RESULTS Sample size calculation revealed that to detect doubling of the breastfeeding rate from 25% to 50% with 80% power and α error of 0.05, 66 participants were required in each group. CONCLUSION There were 75 women with opioid use disorder who had prenatal NAS education (study group) and 108 women with opioid use disorder who underwent standard care before NAS education (control group). Prenatal NAS education participants significantly increased breastfeeding initiation rates compared to the control group. Newborn length of stay significantly decreased after initiation of prenatal NAS education compared to the 36 months before NAS education program.
Collapse
Affiliation(s)
- Brian Brocato
- Department of Obstetrics and Gynecology, University of Alabama, Birmingham, Birmingham, AL, USA
| | - David Lewis
- Department of Obstetrics and Gynecology, Louisiana State University Health, Shreveport, Shreveport, LA, USA
| | - Fabien Eyal
- Division of Neonatology, University of South Alabama, Mobile, AL, USA
| | - Susan Baker
- Department of Obstetrics and Gynecology, University of South Alabama, Mobile, AL, USA
| | - Casey Armistead
- Department of Obstetrics and Gynecology, University of South Alabama, Mobile, AL, USA
| | - Alan David Kaye
- Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University Health Sciences Center, Shreveport, Shreveport, LA, USA
| | - Elyse M Cornett
- Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, USA.
| | | |
Collapse
|
13
|
Affiliation(s)
- Shahla M Jilani
- Office of the Assistant Secretary for Health, US Department of Health and Human Services, Washington, DC
| | - Hendrée E Jones
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina, Chapel Hill
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Jonathan M Davis
- Division of Newborn Medicine, Tufts Medical Center, Boston, Massachusetts
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
| |
Collapse
|
14
|
Devlin LA, Young LW, Kraft WK, Wachman EM, Czynski A, Merhar SL, Winhusen T, Jones HE, Poindexter BB, Wakschlag LS, Salisbury AL, Matthews AG, Davis JM. Neonatal opioid withdrawal syndrome: a review of the science and a look toward the use of buprenorphine for affected infants. J Perinatol 2022; 42:300-306. [PMID: 34556799 PMCID: PMC8459143 DOI: 10.1038/s41372-021-01206-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/17/2021] [Accepted: 09/03/2021] [Indexed: 02/08/2023]
Abstract
Neonates born to mothers taking opioids during pregnancy are at risk for neonatal opioid withdrawal syndrome (NOWS), for which there is no recognized standard approach to care. Nonpharmacologic treatment is typically used as a first-line approach for management, and pharmacologic treatment is added when clinical signs are not responding to nonpharmacologic measures alone. Although morphine and methadone are the most commonly used pharmacotherapies for NOWS, buprenorphine has emerged as a treatment option based on its pharmacologic profile and results from initial single site clinical trials. The objective of this report is to provide an overview of NOWS including a summary of ongoing work in the field and to review the state of the science, knowledge gaps, and practical considerations specific to the use of buprenorphine for the treatment of NOWS as discussed by a panel of experts during a virtual workshop hosted by the National Institutes of Health.
Collapse
Affiliation(s)
- Lori A Devlin
- Department of Pediatrics, Division of Neonatal Medicine, University of Louisville School of Medicine, Louisville, KY, USA.
| | - Leslie W Young
- Department of Pediatrics, The Robert Larner, MD, College of Medicine, University of Vermont, Burlington, VT, USA
| | - Walter K Kraft
- Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, PA, USA
| | - Elisha M Wachman
- Department of Pediatrics, Boston University School of Medicine, Boston, MA, USA
| | - Adam Czynski
- Department of Pediatrics, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Stephanie L Merhar
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - T Winhusen
- Department of Psychiatry and Behavioral Neuroscience, Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Hendrée E Jones
- Department of Obstetrics and Gynecology, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Brenda B Poindexter
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Lauren S Wakschlag
- Department of Medical Social Sciences, Feinberg School of Medicine & Institute for Innovations in Developmental Sciences, Northwestern University, Evanston, IL, USA
| | - Amy L Salisbury
- Virginia Commonwealth University School of Nursing, Richmond, VA, USA
| | | | - Jonathan M Davis
- Department of Pediatrics and the Tufts Clinical and Translational Science Institute, Tufts University School of Medicine, Boston, MA, USA
| |
Collapse
|
15
|
Schroeder M, White J. Neonatal Abstinence Syndrome: Prevention, Recognition, Treatment, and Follow-up. S D Med 2021; 74:576-583. [PMID: 35015949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Neonatal abstinence syndrome (NAS), or neonatal opioid withdrawal syndrome (NOWS) results from acute discontinuation of transplacental opioid exposure following delivery in the setting of maternal opioid use. A rise in the incidence of NAS coincides with the nationwide opioid epidemic. Addressing NAS requires a team approach. First, all pregnant women should be screened for substance use using validated questionnaires. Mothers who screen positive for opioid abuse should be referred to a provider experienced in opioid maintenance therapy. In addition to medical treatment emphasizing stability rather than detoxification, mental and situational health should be addressed. Next, mothers with opioid dependence should be educated regarding NAS. Topics for education include increased length of hospital stay following delivery, neonatal withdrawal symptoms, importance of the mother-baby dyad to treatment, and criteria for pharmacologic intervention. Following delivery, at-risk infants should be evaluated with standardized assessment tool such as Finnegan scoring or the eat-sleep-console tool while simultaneously maximizing nonpharmacologic interventions. Breast-feeding is encouraged in the absence of ongoing illicit or polysubstance use or infectious concerns. Pharmacologic treatment options most commonly include morphine or methadone. Infants without symptoms should be monitored for four to seven days prior to discharge, dependent on type of opioid exposure. Finally, infants with NAS are at risk for long-term mental and physical health problems. Therefore, infants will benefit from connection prior to hospital discharge with a primary care provider as well as entities designed for early childhood intervention and developmental assistance. The importance of well-child exams should be stressed to the family.
Collapse
Affiliation(s)
- Michael Schroeder
- University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota
| | - Jessica White
- Department of Pediatrics, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota
- Sanford Children's Hospital, Department of Pediatrics, Division of Neonatology, Sioux Falls, South Dakota
| |
Collapse
|
16
|
Affiliation(s)
- Margaret H Lloyd Sieger
- From the University of Connecticut School of Social Work, Hartford (M.H.L.S.); the University of Southern California Suzanne Dworak-Peck School of Social Work, Los Angeles (R.R.); and the Vanderbilt Center for Child Health Policy and the Departments of Pediatrics and Health Policy, Division of Neonatology, Vanderbilt University Medical Center, Nashville (S.W.P.)
| | - Rebecca Rebbe
- From the University of Connecticut School of Social Work, Hartford (M.H.L.S.); the University of Southern California Suzanne Dworak-Peck School of Social Work, Los Angeles (R.R.); and the Vanderbilt Center for Child Health Policy and the Departments of Pediatrics and Health Policy, Division of Neonatology, Vanderbilt University Medical Center, Nashville (S.W.P.)
| | - Stephen W Patrick
- From the University of Connecticut School of Social Work, Hartford (M.H.L.S.); the University of Southern California Suzanne Dworak-Peck School of Social Work, Los Angeles (R.R.); and the Vanderbilt Center for Child Health Policy and the Departments of Pediatrics and Health Policy, Division of Neonatology, Vanderbilt University Medical Center, Nashville (S.W.P.)
| |
Collapse
|
17
|
Ko JY, Hirai AH, Owens PL, Stocks C, Patrick SW. Neonatal Abstinence Syndrome and Maternal Opioid-Related Diagnoses: Analysis of ICD-10-CM Transition, 2013-2017. Hosp Pediatr 2021; 11:902-908. [PMID: 34321311 PMCID: PMC11005666 DOI: 10.1542/hpeds.2021-005845] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Hospital discharge records remain a common data source for tracking the opioid crisis among pregnant women and infants. The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) transition from the International Classification of Diseases, Ninth Revision, Clinical Modification may have affected surveillance. Our aim was to evaluate this transition on rates of neonatal abstinence syndrome (NAS), maternal opioid use disorder (OUD), and opioid-related diagnoses (OUD with ICD-10-CM codes for long-term use of opioid analgesics and unspecified opioid use). METHODS Data from the 2013-2017 Healthcare Cost and Utilization Project's National Inpatient Sample were used to conduct, interrupted time series analysis and log-binomial segmented regression to assess whether quarterly rates differed across the transition. RESULTS From 2013 to 2017, an estimated 18.8 million birth and delivery hospitalizations were represented. The ICD-10-CM transition was not associated with NAS rates (rate ratio [RR]: 0.99; 95% confidence interval [CI]: 0.90-1.08; P = .79) but was associated with 11% lower OUD rates (RR: 0.89; 95% CI: 0.80-0.98; P = .02) and a decrease in the quarterly trend (RR: 0.98; 95% CI: 0.96-1.00; P = .04). The transition was not associated with maternal OUD plus long-term use rates (RR: 0.98; 95% CI: 0.89-1.09; P = .76) but was associated with a 20% overall increase in opioid-related diagnosis rates including long-term and unspecified use (RR: 1.20; 95% CI: 1.09-1.32; P < .001). CONCLUSIONS The ICD-10-CM transition did not appear to affect NAS. However, coding of maternal OUD alone may not capture the same population across the transition, which confounds the interpretation of trend data spanning this time period.
Collapse
Affiliation(s)
- Jean Y Ko
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, US Department of Health and Human Services, Atlanta
- Commissioned Corps, US Public Health Service, US Department of Health and Human Services, Rockville, Maryland
| | - Ashley H Hirai
- Maternal and Child Health Bureau, Health Resources and Services Administration
| | - Pamela L Owens
- Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality, US Department of Health and Human Services, Rockville, Maryland
| | - Carol Stocks
- Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality, US Department of Health and Human Services, Rockville, Maryland
| | - Stephen W Patrick
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, US Department of Health and Human Services, Atlanta
- Departments of Pediatrics and Health Policy, Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
18
|
Casavant SG, Meegan T, Fleming M, Hussain N, Gork S, Cong X. Integrated Review of the Assessment of Newborns With Neonatal Abstinence Syndrome. J Obstet Gynecol Neonatal Nurs 2021; 50:539-548. [PMID: 34116058 DOI: 10.1016/j.jogn.2021.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To critically review and summarize current knowledge regarding the assessment of newborns with neonatal abstinence syndrome (NAS). DATA SOURCES We searched the following databases for articles on the assessment of newborns with NAS that were published in English between January 2014 and June 2020: PubMed, CINAHL, and PsycINFO. Keywords and Medical Subject Heading terms used to identify relevant research articles included neonatal abstinence syndrome; Finnegan Scale; eat, sleep, console; epigenetics; genetics; pharmacokinetics; and measurement. We independently reviewed articles for inclusion. STUDY SELECTION We retrieved 435 articles through database searches and 17 through manual reference searches; 31 articles are included in the final review. Excluded articles were duplicates, not relevant to NAS, qualitative studies, and/or of low quality. DATA EXTRACTION We used the methodology of Whittemore and Knafl to guide this integrative review. We extracted and organized data under the following headings: author, year and country, purpose, study design, participants, measurement, biomarker (if applicable), results, limitations, recommendations, and intervention. DATA SYNTHESIS The Finnegan Neonatal Abstinence Scale is the most widely used instrument to measure symptoms of NAS in newborns, although it is very subjective. Recently, there has been a transition from the Finnegan Neonatal Abstinence Scale to the eat, sleep, console method, which consists of structured assessment and intervention and has been shown to decrease length of hospital stay and total opioid treatment dose. Researchers examined biomarkers of NAS, including genetic markers and autonomic nervous system responses, on the variation in incidence and differential severity of NAS. In the included articles, women with opioid use disorder who were treated with naltrexone during pregnancy gave birth to newborns without NAS diagnoses. However, most women who were treated with buprenorphine gave birth to newborns with NAS diagnoses. CONCLUSION NAS negatively affects newborns in a multitude of ways, and the objective assessment and measurement of the newborn's response to withdrawal remains understudied and needs further investigation.
Collapse
|
19
|
Eaves ER, Barber J, Whealy R, Clancey SA, Wright R, Cocking JH, Spadafino J, Hepp CM. Characterization of neonatal opioid withdrawal syndrome in Arizona from 2010-2017. PLoS One 2021; 16:e0248476. [PMID: 34081702 PMCID: PMC8174702 DOI: 10.1371/journal.pone.0248476] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 02/28/2021] [Indexed: 11/21/2022] Open
Abstract
In this paper, we describe a population of mothers who are opioid dependent at the time of giving birth and neonates exposed to opioids in utero who experience withdrawal following birth. While there have been studies of national trends in this population, there remains a gap in studies of regional trends. Using data from the Arizona Department of Health Services Hospital Discharge Database, this study aimed to characterize the population of neonates with neonatal opioid withdrawal syndrome (NOWS) and mothers who were opioid dependent at the time of giving birth, in Arizona. We analyzed approximately 1.2 million electronic medical records from the Arizona Department of Health Services Hospital Discharge Database to identify patterns and disparities across socioeconomic, ethnic, racial, and/or geographic groupings. In addition, we identified comorbid conditions that are differentially associated with NOWS in neonates or opioid dependence in mothers. Our analysis was designed to assess whether indicators such as race/ethnicity, insurance payer, marital status, and comorbidities are related to the use of opioids while pregnant. Our findings suggest that women and neonates who are non-Hispanic White and economically disadvantaged, tend be part of our populations of interest more frequently than expected. Additionally, women who are opioid dependent at the time of giving birth are unmarried more often than expected, and we suggest that marital status could be a proxy for support. Finally, we identified comorbidities associated with neonates who have NOWS and mothers who are opioid dependent not previously reported.
Collapse
Affiliation(s)
- Emery R. Eaves
- Department of Anthropology, Northern Arizona University, Flagstaff, Arizona, United States of America
- Center for Health Equity Research, Northern Arizona University, Flagstaff, Arizona, United States of America
- Southwest Health Equity Research Collaborative, Northern Arizona University, Flagstaff, Arizona, United States of America
| | - Jarrett Barber
- Southwest Health Equity Research Collaborative, Northern Arizona University, Flagstaff, Arizona, United States of America
- School of Informatics, Computing, and Cyber Systems, Northern Arizona University, Flagstaff, Arizona, United States of America
| | - Ryann Whealy
- School of Informatics, Computing, and Cyber Systems, Northern Arizona University, Flagstaff, Arizona, United States of America
- Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, Arizona, United States of America
| | - Sara A. Clancey
- Institute for Human Development, Northern Arizona University, Flagstaff, Arizona, United States of America
| | - Rita Wright
- Department of Social Work, Northern Arizona University, Flagstaff, Arizona, United States of America
| | - Jill Hager Cocking
- School of Informatics, Computing, and Cyber Systems, Northern Arizona University, Flagstaff, Arizona, United States of America
- Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, Arizona, United States of America
| | - Joseph Spadafino
- Arizona Department of Health Services, Phoenix, Arizona, United States of America
| | - Crystal M. Hepp
- Southwest Health Equity Research Collaborative, Northern Arizona University, Flagstaff, Arizona, United States of America
- School of Informatics, Computing, and Cyber Systems, Northern Arizona University, Flagstaff, Arizona, United States of America
- Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, Arizona, United States of America
- * E-mail:
| |
Collapse
|
20
|
Yen E, Murphy HJ, Friedman H, Lucke AM, Rodday AM. Neonatal abstinence syndrome practice variations across pediatric subspecialty. J Perinatol 2021; 41:1512-1514. [PMID: 32968221 PMCID: PMC7985043 DOI: 10.1038/s41372-020-00831-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 08/22/2020] [Accepted: 09/14/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Elizabeth Yen
- Department of Pediatrics, Tufts Medical Center, Boston, MA, USA.
| | - Heidi J Murphy
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Hayley Friedman
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Ashley M Lucke
- Department of Pediatrics, University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Angie Mae Rodday
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| |
Collapse
|
21
|
Hirai AH, Ko JY, Patrick SW. US Hospital Data About Neonatal Abstinence Syndrome and Maternal Opioid-Related Diagnoses-Reply. JAMA 2021; 325:2120. [PMID: 34032835 PMCID: PMC11008180 DOI: 10.1001/jama.2021.4519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Ashley H Hirai
- Health Resources and Services Administration, US Department of Health and Human Services, Rockville, Maryland
| | - Jean Y Ko
- Centers for Disease Control and Prevention, US Department of Health and Human Services, Atlanta, Georgia
| | - Stephen W Patrick
- Departments of Pediatrics and Health Policy, Vanderbilt Center for Child Health Policy, Nashville, Tennessee
| |
Collapse
|
22
|
Meyer M, Metayer J. US Hospital Data About Neonatal Abstinence Syndrome and Maternal Opioid-Related Diagnoses. JAMA 2021; 325:2119-2120. [PMID: 34032837 DOI: 10.1001/jama.2021.4510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Marjorie Meyer
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Vermont, Burlington
| | - Jerilyn Metayer
- Department of Pediatrics, University of Vermont Medical Center, Burlington
| |
Collapse
|
23
|
Doherty KM, Scott TA, Morad A, Crook T, McNeer E, Lovell KS, Gay JC, Patrick SW. Evaluating Definitions for Neonatal Abstinence Syndrome. Pediatrics 2021; 147:e2020007393. [PMID: 33268396 PMCID: PMC7780959 DOI: 10.1542/peds.2020-007393] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVES National estimates indicate that the incidence of neonatal abstinence syndrome (NAS), a postnatal opioid withdrawal syndrome, increased more than fivefold between 2004 and 2016. There is no gold standard definition for capturing NAS across clinical, research, and public health settings. Our objective was to evaluate how different definitions of NAS modify the calculated incidence when applied to a known population of opioid-exposed infants. METHODS Data for this retrospective cohort study were obtained from opioid-exposed infants born at Vanderbilt University Medical Center in 2018. Six commonly used clinical and surveillance definitions of opioid exposure and NAS were applied to the study population and evaluated for accuracy in assessing clinical withdrawal. RESULTS A total of 121 opioid-exposed infants met the criteria for inclusion in our study. The proportion of infants who met criteria for NAS varied by predefined definition, ranging from 17.4% for infants who received morphine to 52.8% for infants with the diagnostic code for opioid exposure. Twenty-eight infants (23.1%) received a clinical diagnosis of NAS by a medical provider, and 38 (34.1%) received the diagnostic code for NAS at discharge. CONCLUSIONS We found significant variability in the incidence of opioid exposure and NAS among a single-center population using 6 common definitions. Our findings suggest a need to develop a gold standard definition to be used across clinical, research, and public health surveillance settings.
Collapse
Affiliation(s)
- Kathleen M Doherty
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee;
| | - Theresa A Scott
- Vanderbilt Center for Child Health Policy, Nashville, Tennessee; and
| | - Anna Morad
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Travis Crook
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Elizabeth McNeer
- Vanderbilt Center for Child Health Policy, Nashville, Tennessee; and
- Department of Biostatistics, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Kim S Lovell
- Vanderbilt Center for Child Health Policy, Nashville, Tennessee; and
| | - James C Gay
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephen W Patrick
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Center for Child Health Policy, Nashville, Tennessee; and
| |
Collapse
|
24
|
Young LW, Hu Z, Annett RD, Das A, Fuller JF, Higgins RD, Lester BM, Merhar SL, Simon AE, Ounpraseuth S, Smith PB, Crawford MM, Atz AM, Cottrell LE, Czynski AJ, Newman S, Paul DA, Sánchez PJ, Semmens EO, Smith MC, Turley CB, Whalen BL, Poindexter BB, Snowden JN, Devlin LA. Site-Level Variation in the Characteristics and Care of Infants With Neonatal Opioid Withdrawal. Pediatrics 2021; 147:e2020008839. [PMID: 33386337 PMCID: PMC7780957 DOI: 10.1542/peds.2020-008839] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Variation in pediatric medical care is common and contributes to differences in patient outcomes. Site-to-site variation in the characteristics and care of infants with neonatal opioid withdrawal syndrome (NOWS) has yet to be quantified. Our objective was to describe site-to-site variation in maternal-infant characteristics, infant management, and outcomes for infants with NOWS. METHODS Cross-sectional study of 1377 infants born between July 1, 2016, and June 30, 2017, who were ≥36 weeks' gestation, with NOWS (evidence of opioid exposure and NOWS scoring within the first 120 hours of life) born at or transferred to 1 of 30 participating hospitals nationwide. Site-to-site variation for each parameter within the 3 domains was measured as the range of individual site-level means, medians, or proportions. RESULTS Sites varied widely in the proportion of infants whose mothers received adequate prenatal care (31.3%-100%), medication-assisted treatment (5.9%-100%), and prenatal counseling (1.9%-75.5%). Sites varied in the proportion of infants with toxicology screening (50%-100%) and proportion of infants receiving pharmacologic therapy (6.7%-100%), secondary medications (1.1%-69.2%), and nonpharmacologic interventions including fortified feeds (2.9%-90%) and maternal breast milk (22.2%-83.3%). The mean length of stay varied across sites (2-28.8 days), as did the proportion of infants discharged with their parents (33.3%-91.1%). CONCLUSIONS Considerable site-to-site variation exists in all 3 domains. The magnitude of the observed variation makes it unlikely that all infants are receiving efficient and effective care for NOWS. This variation should be considered in future clinical trial development, practice implementation, and policy development.
Collapse
Affiliation(s)
- Leslie W Young
- Department of Pediatrics, The Robert Larner, M.D. College of Medicine, The University of Vermont, Burlington, Vermont;
| | | | - Robert D Annett
- Department of Pediatrics, Medical Center, University of Mississippi, Jackson, Mississippi
| | - Abhik Das
- Research Triangle Institute International, Rockville, Maryland
| | - Janell F Fuller
- Health Sciences Center, The University of New Mexico, Albuquerque, New Mexico
| | - Rosemary D Higgins
- National Institute of Child Health and Human Development, Bethesda, Maryland
- College of Health and Human Services, George Mason University, Fairfax, Virginia
| | - Barry M Lester
- Department of Pediatrics and Center for the Study of Children at Risk, Warren Alpert Medical School, Brown University and
| | - Stephanie L Merhar
- Division of Neonatology and Perinatal Institute and
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Alan E Simon
- Environmental Influences on Child Health Outcomes Program and Office of the Director, National Institutes of Health, Rockville, Maryland
| | | | - P Brian Smith
- Duke Clinical Research Institute, School of Medicine, Duke University, Durham, North Carolina;
| | | | - Andrew M Atz
- Department of Pediatrics, College of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Lesley E Cottrell
- Department of Pediatrics, School of Medicine, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown, West Virginia
| | - Adam J Czynski
- Department of Pediatrics, Women and Infants Hospital, Providence, Rhode Island
| | | | - David A Paul
- Division of Neonatology, Department of Pediatrics, ChristianaCare, Newark, Delaware
| | - Pablo J Sánchez
- Nationwide Children's Hospital and College of Medicine, The Ohio State University, Columbus, Ohio
| | - Erin O Semmens
- School of Public and Community Health Sciences, University of Montana, Missoula, Montana
| | - M Cody Smith
- Department of Pediatrics, School of Medicine, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown, West Virginia;
| | - Christine B Turley
- Department of Pediatrics, School of Medicine, University of South Carolina, Columbia, South Carolina
| | - Bonny L Whalen
- Children's Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; and
| | | | - Jessica N Snowden
- Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Lori A Devlin
- Department of Pediatrics, School of Medicine, University of Louisville, Louisville, Kentucky
| |
Collapse
|
25
|
Curran M, Holt C, Arciero M, Quinlan J, Cox D, Craig A. Proxy Finnegan Component Scores for Eat, Sleep, Console in a Cohort of Opioid-Exposed Neonates. Hosp Pediatr 2020; 10:1053-1058. [PMID: 33199395 DOI: 10.1542/hpeds.2020-0190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVES The Finnegan Neonatal Abstinence Score (FNAS) monitors infants with neonatal abstinence syndrome (NAS), but it has been criticized for being time consuming and subjective. Many institutions have transitioned to a more straightforward screening tool, Eat, Sleep, Console (ESC), an assessment based on 3 simple observations with a focus on maximizing nonpharmacologic therapies. We aimed to compare the sensitivity and specificity of the ESC with that of the FNAS to determine if infants who needed pharmacologic therapy could potentially be missed when assessed by using ESC. METHODS A retrospective cohort study of infants identified by International Classification of Diseases, Ninth Revision and International Classification of Diseases, 10th Revision billing codes for NAS. FNAS scores were recorded every 4 hours for the entire hospitalization. ESC proxy scores were created by using components of the FNAS that referenced eating, sleeping, and consoling. Detailed demographic and clinical data were manually extracted regarding opioid exposures and pharmacologic treatment of NAS. RESULTS From 2013 to 2016, 423 infants ≥37 weeks' gestation had a total of 33 115 FNAS scores over 921 days of observation. In total, 287 (68%) were exposed to buprenorphine, 100 (23.7%) were exposed to methadone, and 165 (39%) were pharmacologically treated. The FNAS was 94.8% sensitive and 63.5% specific for pharmacologic treatment, and the ESC proxy variables were 99.4% sensitive and 40.2% specific (P < .01). CONCLUSIONS ESC proxy variables have slightly higher sensitivity compared with FNAS, suggesting that ESC use is unlikely to miss infants requiring treatment who would have been identified by FNAS. Transitioning from FNAS to ESC is not likely to impair the care of infants with NAS.
Collapse
Affiliation(s)
- Margaret Curran
- Department of Family Medicine, Maine Medical Center, Portland, Maine; and
| | - Christina Holt
- Department of Family Medicine, Maine Medical Center, Portland, Maine; and
| | - Michael Arciero
- Department of Mathematical Sciences, University of New England, Biddeford, Maine
| | - James Quinlan
- Department of Mathematical Sciences, University of New England, Biddeford, Maine
| | - David Cox
- Department of Pediatrics, The Barbara Bush Children's Hospital and
| | - Alexa Craig
- Department of Pediatrics, The Barbara Bush Children's Hospital and
| |
Collapse
|
26
|
Flannery T, Davis JM, Czynski AJ, Dansereau LM, Oliveira EL, Camardo SA, Lester BM. Neonatal Abstinence Syndrome Severity Index Predicts 18-Month Neurodevelopmental Outcome in Neonates Randomized to Morphine or Methadone. J Pediatr 2020; 227:101-107.e1. [PMID: 32805259 PMCID: PMC7731918 DOI: 10.1016/j.jpeds.2020.08.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/09/2020] [Accepted: 08/12/2020] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To develop an index to determine which opioid-exposed neonates have the most severe neonatal abstinence syndrome (NAS). STUDY DESIGN Full-term neonates with NAS (n = 116) from mothers maintained on methadone or buprenorphine were enrolled from 8 sites into a randomized clinical trial of morphine vs methadone. Ninety-nine (85%) were evaluated at hospital discharge using the NICU Network Neurobehavioral Scale (NNNS). At 18 months, 83 of 99 (83.8%) were evaluated with the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III), and 77 of 99 (77.7%) were evaluated with the Child Behavior Checklist (CBCL). RESULTS Cluster analysis was used to define high (n = 21) and low (n = 77) NAS severity. Compared with infants in the low NAS severity cluster, infants in the high NAS severity cluster had a longer length of stay (P < .001), longer length of stay due to NAS (P < .001), longer duration of treatment due to NAS (P < .001), and higher total dose of the study drug (P < .001) and were more likely to have received phenobarbital (P < .001), to have been treated with morphine (P = .020), and to have an atypical NNNS profile (P = .005). The 2 groups did not differ in terms of maximum Finnegan score. At 18 months, in unadjusted analyses, compared with the high-severity cluster, the low-severity cluster had higher scores on the Bayley-III Cognitive (P = .013), Language (P < .001), and Motor (P = .041) composites and less total behavior problems on the CBCL (P = .028). In adjusted analyses, the difference in the Bayley-III Language composite remained (P = .013). CONCLUSIONS Presumptive measures of NAS severity can be aggregated to develop an index that predicts developmental outcomes at age 18 months.
Collapse
Affiliation(s)
- Tess Flannery
- Brown Center for the Study of Children at Risk and Women and Infants Hospital, Providence, RI
| | - Jonathan M Davis
- Department of Pediatrics, The Floating Hospital for Children at Tufts Medical Center, Boston, MA; Tufts Clinical and Translational Science Institute, Boston, MA; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
| | - Adam J Czynski
- Department of Pediatrics, Warren Alpert Medical School of Brown University and Women and Infants Hospital, Providence, RI
| | - Lynne M Dansereau
- Brown Center for the Study of Children at Risk and Women and Infants Hospital, Providence, RI
| | - Erica L Oliveira
- Brown Center for the Study of Children at Risk and Women and Infants Hospital, Providence, RI
| | - Samantha A Camardo
- Brown Center for the Study of Children at Risk and Women and Infants Hospital, Providence, RI
| | - Barry M Lester
- Brown Center for the Study of Children at Risk and Women and Infants Hospital, Providence, RI; Department of Pediatrics, Warren Alpert Medical School of Brown University and Women and Infants Hospital, Providence, RI; Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI.
| |
Collapse
|
27
|
Wouldes TA, Woodward LJ. Neurobehavior of newborn infants exposed prenatally to methadone and identification of a neurobehavioral profile linked to poorer neurodevelopmental outcomes at age 24 months. PLoS One 2020; 15:e0240905. [PMID: 33064777 PMCID: PMC7567379 DOI: 10.1371/journal.pone.0240905] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 10/05/2020] [Indexed: 11/25/2022] Open
Abstract
The abuse of prescription opioids and heroin by women of childbearing age over the past decade has resulted in a five-fold increase in the number of infants born opioid-dependent. Daily opioid substitution treatment with methadone is associated with less maternal illicit opioid use and improved antenatal care. However, research on the neurobehavioral effects of daily prenatal exposure to methadone on the infant is limited. Using the NICU Network Neurobehavioral Scale (NNNS), we compared the neurobehavior at birth of 86 infants born to opioid-dependent mothers receiving methadone treatment (MMT) with 103 infants unexposed to methadone. Generalized linear models, adjusted for covariates, showed methadone exposed infants had significantly poorer attention, regulation, and quality of movement. They were also significantly more excitable, more easily aroused, exhibited more non-optimal reflexes, hypertonicity, and total signs of stress abstinence. Maternal MMT was also associated with more indices of neonatal abstinence, including: CNS, visual, genitourinary (GI), and state. Latent profile analysis of the NNNS summary scores revealed four distinct neurobehavioral profiles with infants characterized by the most disturbed neurobehavior at birth having the poorest clinical outcomes at birth, and poorer cognitive and motor development at 24 months of age.
Collapse
Affiliation(s)
- Trecia A. Wouldes
- Department of Psychological Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Lianne J. Woodward
- School of Health Sciences, University of Canterbury, Christchurch, New Zealand
| |
Collapse
|
28
|
Abstract
In the past two decades, the incidence of neonatal abstinence syndrome (NAS) has risen fivefold, mirroring the rise of opioid use disorder (OUD) among pregnant women. The resulting increases in length of stay and neonatal intensive care utilization are associated with higher hospital costs, particularly among Medicaid-financed deliveries. Pregnant women with OUD require comprehensive medical and psychosocial evaluation and management; this combined with medication-assisted treatment is critical to optimize maternal and newborn outcomes. Multidisciplinary collaboration and standardized approaches to screening for intrauterine opioid exposure, evaluation and treatment of NAS, and discharge planning are important for clinical outcomes and may improve maternal experience of care.
Collapse
Affiliation(s)
- Neera K Goyal
- Department of Pediatrics, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
- Nemours/AI duPont Hospital for Children, Wilmington, Delaware
| | - Jennifer McAllister
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| |
Collapse
|
29
|
Chandler A, Whittaker A, Cunningham-Burley S, Elliott L, Midgley P, Cooper S. Diagnosing uncertainty, producing neonatal abstinence syndrome. Sociol Health Illn 2020; 42 Suppl 1:35-50. [PMID: 31900970 DOI: 10.1111/1467-9566.13000] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The use of alcohol and other drugs during pregnancy is understood to be an important public health problem. One way in which this problem is expressed and responded to is via the identification and treatment of neonatal abstinence syndrome (NAS). In this article, we demonstrate how the processes of anticipating, identifying and responding to NAS are characterised by significant uncertainty among parents and health and social care practitioners. We draw on interviews with 16 parents who had recently had a baby at risk of NAS, and multidisciplinary focus groups with 27 health and social care professionals, held in Scotland, UK. NAS, and drug use in pregnancy, is a fraught and complex arena. Parents in the UK who use opioids risk losing custody of children, and must navigate a high degree of surveillance, governance and marginalisation. We suggest that considering NAS as a social diagnosis, further informed by Mol's political ontology of 'multiple' bodies/diseases, may help to produce clinical and social responses to uncertainty which avoid, rather than promote, further marginalisation of parents who use drugs. One such response is to develop a culture of relationship-based care which empowers both service providers and service users to challenge existing practice and decision-making.
Collapse
Affiliation(s)
- Amy Chandler
- School of Health in Social Science, University of Edinburgh, Edinburgh, UK
| | - Anne Whittaker
- NMAHP Research Unit, University of Stirling, Stirling, UK
| | | | - Lawrie Elliott
- Department of Nursing and Community Health, Glasgow Caledonian University, Glasgow, UK
| | | | | |
Collapse
|
30
|
Goyal S, Saunders KC, Moore CS, Fillo KT, Ko JY, Manning SE, Shapiro-Mendoza C, Gupta M, Romero L, Coy KC, McDow KB, Keaton AA, Sinatra J, Jones K, Alpren C, Barfield WD, Diop H. Identification of Substance-Exposed Newborns and Neonatal Abstinence Syndrome Using ICD-10-CM - 15 Hospitals, Massachusetts, 2017. MMWR Morb Mortal Wkly Rep 2020; 69:951-955. [PMID: 32701936 PMCID: PMC7377822 DOI: 10.15585/mmwr.mm6929a2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
|
31
|
Devlin LA, Breeze JL, Terrin N, Gomez Pomar E, Bada H, Finnegan LP, O’Grady KE, Jones HE, Lester B, Davis JM. Association of a Simplified Finnegan Neonatal Abstinence Scoring Tool With the Need for Pharmacologic Treatment for Neonatal Abstinence Syndrome. JAMA Netw Open 2020; 3:e202275. [PMID: 32267513 PMCID: PMC7142377 DOI: 10.1001/jamanetworkopen.2020.2275] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
IMPORTANCE Observer-rated scales, such as the Finnegan Neonatal Abstinence Scoring Tool (FNAST), are used to quantify the severity of neonatal abstinence syndrome (NAS) and guide pharmacologic therapy. The FNAST, a comprehensive 21-item assessment tool, was developed for research and subsequently integrated into clinical practice; a simpler tool, designed to account for clinically meaningful outcomes, is urgently needed to standardize assessment. OBJECTIVES To identify FNAST items independently associated with the decision to use pharmacologic therapy and to simplify the FNAST while minimizing loss of information for the treatment decision. DESIGN, SETTING, AND PARTICIPANTS This multisite cohort study included 424 neonates with opioid exposure who had a gestational age of at least 36 weeks with follow-up from birth to hospital discharge in the derivation cohort and 109 neonates with opioid exposure from the Maternal Opioid Treatment: Human Experimental Research Study in the validation cohort. Neonates in the derivation cohort were included in a medical record review at the Universities of Louisville and Kentucky or in a randomized clinical trial and observational study conducted at Tufts University (2014-2018); the Maternal Opioid Treatment: Human Experimental Research was conducted from 2005 to 2008. Data analysis was conducted from May 2017 to August 2019. EXPOSURES Prenatal opioid exposure. MAIN OUTCOMES AND MEASURES All FNAST items were dichotomized as present or not present, and logistic regression was used to identify binary items independently associated with pharmacologic treatment. The final model was validated with an independent cohort of neonates with opioid exposure. RESULTS Among 424 neonates (gestational age, ≥36 weeks; 217 [51%] female infants), convulsions were not observed, and high-pitched cry and hyperactive Moro reflex had extremely different frequencies across cohorts. Therefore, these 3 FNAST items were removed from further analysis. The 2 tremor items were combined, and 8 of the remaining 17 items were independently associated with pharmacologic treatment, with an area under the curve of 0.86 (95% CI, 0.82-0.89) compared with 0.90 (95% CI, 0.87-0.94) for the 21-item FNAST. External validation of the 8 items resulted in an area under the curve of 0.86 (95% CI, 0.79-0.93). Thresholds of 4 and 5 on the simplified scale yielded the closest agreement with FNAST thresholds of 8 and 12 (weighted κ = 0.55; 95% CI, 0.48-0.61). CONCLUSIONS AND RELEVANCE The findings of this study suggest that 8 signs of NAS may be sufficient to assess whether a neonate meets criteria for pharmacologic therapy. A focus on these signs could simplify the FNAST tool and may enhance its clinical utility.
Collapse
Affiliation(s)
- Lori A. Devlin
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky
| | - Janis L. Breeze
- Tufts Clinical and Translational Science Institute, Boston, Massachusetts
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Norma Terrin
- Tufts Clinical and Translational Science Institute, Boston, Massachusetts
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | | | | | | | | | | | - Barry Lester
- Women and Infants Hospital, Providence, Rhode Island
| | - Jonathan M. Davis
- Tufts Clinical and Translational Science Institute, Boston, Massachusetts
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
- The Floating Hospital for Children at Tufts Medical Center, Boston, Massachusetts
| |
Collapse
|
32
|
Clemans-Cope L, Holla N, Lee HC, Cong AS, Castro R, Chyi L, Huang A, Taylor KJ, Kenney GM. Neonatal abstinence syndrome management in California birth hospitals: results of a statewide survey. J Perinatol 2020; 40:463-472. [PMID: 31911649 PMCID: PMC7042156 DOI: 10.1038/s41372-019-0568-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 11/22/2019] [Accepted: 12/18/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Assess management of neonatal abstinence syndrome (NAS) in California hospitals to identify potential opportunities to expand the use of best practices. STUDY DESIGN We fielded an internet-based survey of 37 questions to medical directors or nurse managers at 145 birth hospitals in California. RESULTS Seventy-five participants (52%) responded. Most respondents reported having at least one written protocol for managing NAS, but gaps included protocols for pharmacologic management. Newer tools for assessing NAS severity were not commonly used. About half reported usually or always using nonpharmacologic strategies; there is scope for increasing breastfeeding when recommended, skin-to-skin care, and rooming-in. CONCLUSIONS We found systematic gaps in care for infants with NAS in a sample of California birth hospitals, as well as opportunities to spread best practices. Adoption of new approaches will vary across hospitals. A concerted statewide effort to facilitate such implementation has strong potential to increase access to evidence-based treatment for infants and mothers.
Collapse
Affiliation(s)
- Lisa Clemans-Cope
- The Urban Institute, 500 L'Enfant Plaza SW, Washington, DC, 20037, USA.
| | - Nikhil Holla
- George Washington University, Washington, DC, USA
| | - Henry C Lee
- Division of Neonatal & Developmental Medicine, Stanford University, Stanford, CA, USA
| | - Allison Shufei Cong
- California Perinatal Quality Care Collaborative (CPQCC), Stanford University, Stanford, CA, USA
| | - Robert Castro
- Division of Neonatal & Developmental Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Lisa Chyi
- Walnut Creek Medical Center, Kaiser Northern California NAS Workgroup Co-chair, Walnut Creek, CA, USA
| | - Angela Huang
- Department of Neonatology, Santa Clara Valley Medical Center, San Jose, CA, USA
| | - Kimá Joy Taylor
- The Urban Institute, 500 L'Enfant Plaza SW, Washington, DC, 20037, USA
| | | |
Collapse
|
33
|
Baloch RQ, Pinto JM, Greenberg P, Kuo YH, Siu A. Evaluation and analysis of the Modified Finnegan Scoring System for assessment of neonatal abstinence syndrome. J Opioid Manag 2020; 16:189-196. [PMID: 32421839 DOI: 10.5055/jom.2020.0567] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
OBJECTIVE The Finnegan Neonatal Abstinence Scoring System (FNASS) is the most commonly used scoring system for neonatal abstinence syndrome (NAS) both in its original and modified versions, despite challenges related to tool length and observer bias. The purpose of this study was to determine the most frequent symptoms of NAS that led to score elevation and prompted initiation of drug therapy on the Modified Finnegan (MF). We also sought to identify vital sign changes associated with score elevation. DESIGN We conducted a retrospective study of neonates diagnosed with NAS, based on ICD-9 codes and charge data for methadone administration. SETTING The study setting was in a Level III Neonatal Intensive Care Unit. PATIENTS, PARTICIPANTS Ninety patients with a total of 286 MF scores recorded from 2011 to 2015 met inclusion criteria. MAIN OUTCOME MEASURE(S) The primary outcome was overall occurrence for each specific component of the MF scoring tool during symptomatic periods. Secondary outcomes were vital sign changes. RESULTS Among the MF elements, there were 13 components that were scored more often than others in symptomatic infants. Respiratory rate (RR) was elevated in infants with NAS, but other vital signs did not differ from age-specific norms. CONCLUSIONS Of the various signs of NAS used to score the MF, few are frequently observed. Our study reinforces literature that proposes a shortened MF assessment tool. Experimental research will be needed to determine the efficacy of a shortened MF tool for diagnosing NAS.
Collapse
Affiliation(s)
- Rafia Q Baloch
- Department of Pediatrics, Jersey Shore University Medical Center, Neptune, New Jersey; Department of Pediatrics, Urgent Care, Emergency Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Jamie M Pinto
- Department of Pediatrics, Jersey Shore University Medical Center, Neptune, New Jersey
| | - Patricia Greenberg
- Office of Research Administration, Jersey Shore University Medical Center, Neptune, New Jersey
| | - Yen-Hong Kuo
- Office of Research Administration, Jersey Shore University Medical Center, Neptune, New Jersey
| | - Anita Siu
- Clinical Neonatal/Pediatric Pharmacotherapy Specialist, Department of Pharmacy and Pediatrics, Jersey Shore University Medical Center, Clinical Professor, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, New Jersey
| |
Collapse
|
34
|
Abstract
Opioid use and abuse have skyrocketed in the United States over the last decade. As a result, we have seen a substantial increase in neonates who are exposed to opioids in-utero. Anywhere from 55% to 94% of infants exposed to opioids will experience withdrawal, known as neonatal abstinence syndrome (NAS), and will require management of their symptoms in the hospital. It is important to know what to look for in an infant who is experiencing NAS, how to determine if treatment is needed and what type of treatment is indicated, and how to prepare the infant for discharge once they are stable. Unfortunately, there are no standardized care plans in place for the management of this population. Although assessment tools such as the Finnegan scoring systems are available, they are not validated and can be cumbersome and difficult to administer. Other methods of assessment are being studied and may prove to be more useful in the clinical setting of neonatal withdrawal. Neither nonpharmacologic nor pharmacologic interventions are standardized, with individual institutions determining their plan of care. Development of more standardized care could significantly improve the management of these patients. [Pediatr Ann. 2020;49(1):e3-e7.].
Collapse
|
35
|
van Donge T, Samiee‐Zafarghandy S, Pfister M, Koch G, Kalani M, Bordbar A, van den Anker J. Methadone dosing strategies in preterm neonates can be simplified. Br J Clin Pharmacol 2019; 85:1348-1356. [PMID: 30805946 PMCID: PMC6533437 DOI: 10.1111/bcp.13906] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 02/14/2019] [Accepted: 02/21/2019] [Indexed: 01/11/2023] Open
Abstract
AIMS A dramatic increase in newborn infants with neonatal abstinence syndrome has been observed and these neonates are frequently treated with complex methadone dosing schemes to control their withdrawal symptoms. Despite its abundant use, hardly any data on the pharmacokinetics (PK) of methadone is available in preterm neonates. Therefore we investigated developmental PK of methadone and evaluated current dosing strategies and possible simplification in this vulnerable population. METHODS A single-centre open-label prospective study was performed to collect PK data after a single oral dose of methadone in preterm neonates. A population PK model was built to characterize developmental PK of (R)- and (S)-methadone. Model-based simulations were performed to identify a simplified dosing strategy to reach and maintain target methadone exposure. RESULTS A total of 121 methadone concentrations were collected from 31 preterm neonates. A one-compartment model with first order absorption and elimination kinetics best described PK data for (R)- and (S)-methadone. Clearance increases with advancing gestational age and differs between R- and S-enantiomer, being slightly higher for the former (0.244 vs 0.167 L/h). Preterm neonates reached target exposure after 48 hours with currently used dosing schedules. Output from simulations revealed that target exposures can be achieved with a simplified dosing strategy during the first 4 days of treatment. CONCLUSION Methadone clearance in preterm neonates increases with advancing gestational age and its disposition is influenced by its chirality. Simulations that account for developmental PK changes indicate a shorter methadone dosing strategy can maintain target exposure to control withdrawal symptoms.
Collapse
Affiliation(s)
- Tamara van Donge
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital BaselUniversity of BaselBaselSwitzerland
| | | | - Marc Pfister
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital BaselUniversity of BaselBaselSwitzerland
- Certara LPPrincetonNJUSA
| | - Gilbert Koch
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital BaselUniversity of BaselBaselSwitzerland
| | - Majid Kalani
- Department of Pediatrics, Shahid Akbarabadi HospitalIran University of Medical SciencesTehranIran
| | - Arash Bordbar
- Department of Pediatrics, Shahid Akbarabadi HospitalIran University of Medical SciencesTehranIran
| | - John van den Anker
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital BaselUniversity of BaselBaselSwitzerland
- Intensive Care and Department of Pediatric SurgeryErasmus MC‐Sophia Children's HospitalRotterdamThe Netherlands
- Division of Clinical PharmacologyChildren's National Health SystemWashingtonDCUSA
| |
Collapse
|
36
|
Abstract
This review examines the continuum of care of opioid-exposed infants, including the assessment of the neonate, diagnosis of neonatal abstinence syndrome, management of the syndrome including nonpharmacologic and pharmacologic care, approach to breastfeeding, pediatric follow-up care, and integration of care of the mother-infant dyad.
Collapse
Affiliation(s)
- Lauren M Jansson
- The Center for Addiction and Pregnancy, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, D4E, Baltimore, MD 21224, USA.
| | - Stephen W Patrick
- Vanderbilt Center for Child Health Policy, 2525 West End Avenue, Suite 1200, Nashville, TN 37027, USA
| |
Collapse
|
37
|
Abstract
Infants with in-utero opioid exposure are most commonly assessed using the Finnegan Neonatal Abstinence Scoring System (FNASS) or a modified version of that tool. Traditionally, the purpose of these tools has been to characterize the extent of withdrawal signs to guide the pharmacologic treatment for infants with neonatal opioid withdrawal syndrome (NOWS). In the past decade however, in response to some of the limitations of the FNASS tool, there has been an increasing emphasis on developing novel assessment tools not based on the FNASS in addition to the promotion of non-pharmacologic treatment options as the first line treatment for infants with opioid exposure. Additionally, several prediction tools that may be useful in determining which patients are at high or low risk for receiving pharmacologic therapy have been developed. In this review, we will evaluate the clinical utility of these novel tools and will consider new avenues for future research.
Collapse
Affiliation(s)
- Davida M Schiff
- Division of General Academic Pediatrics, MassGeneral Hospital for Children, 125 Nashua St #8630, USA.
| | - Matthew R Grossman
- Yale School of Medicine, Department of Pediatrics, 333 Cedar St., PO Box 208064, New Haven, CT, 06520-8064, USA.
| |
Collapse
|
38
|
Auger N, Luu TM, Healy-Profitós J, Gauthier A, Lo E, Fraser WD. Correlation of Neonatal Abstinence Syndrome With Risk of Birth Defects and Infant Morbidity. J Stud Alcohol Drugs 2018; 79:553-560. [PMID: 30079870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023] Open
Abstract
OBJECTIVE Infants with neonatal abstinence syndrome have significant morbidity, but the association with birth defects is poorly understood. This study aimed to determine how neonatal abstinence syndrome is related to birth defects, including the joint impact of neonatal abstinence syndrome and birth defects on infant morbidity. METHOD A population-based cohort of 1,944,804 neonates born in the hospitals of Quebec, Canada (1989-2013), was compiled with data on maternal exposures and infant outcomes after delivery. The prevalence of neonatal abstinence syndrome and birth defects was estimated, including the association with neonatal morbidity and mortality after adjustment for maternal age, parity, morbidity, socioeconomic deprivation, and time period. Joint effects of neonatal abstinence syndrome and birth defects on infant outcomes were assessed. RESULTS Infants with neonatal abtinence syndrome had a higher prevalence of birth defects (705.7 per 10,000) than infants with no drug exposure (568.9 per 10,000). Compared with no exposure, infants with neonatal abstinence syndrome had 1.35 times the chance of having birth defects (95% confidence interval [1.14, 1.59]). Associations were strongest for central nervous system defects (risk ratio = 6.06, 95% confidence interval [3.93, 9.35]). Neonatal abstinence syndrome combined with birth defects was associated with significantly more infant morbidity and mortality. CONCLUSIONS Infants with neonatal abstinence syndrome have a greater prevalence of birth defects, particularly defects of the central nervous system. Neonatal abstinence syndrome with birth defects may be an underappreciated contributor to infant morbidity.
Collapse
Affiliation(s)
- Nathalie Auger
- University of Montreal Hospital Research Centre, Montreal, Quebec, Canada
- Institut national de santé publique du Québec, Montreal, Quebec, Canada
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Thuy Mai Luu
- Department of Pediatrics, Sainte Justine Hospital Research Centre, Montreal, Quebec, Canada
| | - Jessica Healy-Profitós
- University of Montreal Hospital Research Centre, Montreal, Quebec, Canada
- Institut national de santé publique du Québec, Montreal, Quebec, Canada
| | - Annick Gauthier
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Ernest Lo
- Institut national de santé publique du Québec, Montreal, Quebec, Canada
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - William D Fraser
- Department of Obstetrics & Gynecology, Sherbrooke University Hospital Research Centre, Sherbrooke, Quebec, Canada
| |
Collapse
|
39
|
Abstract
IMPORTANCE Neonatal abstinence syndrome, which occurs as a result of in utero opioid exposure, affects between 6.0 and 20 newborns per 1000 live US births. There is substantial variability in how neonatal abstinence syndrome is diagnosed and managed. OBJECTIVE To summarize key studies examining the diagnosis and management (both pharmacologic and nonpharmacologic) of neonatal abstinence syndrome published during the past 10 years. EVIDENCE REVIEW PubMed, Web of Science, and CINAHL were searched for articles published between July 1, 2007, and December 31, 2017. Abstracts were screened and included in the review if they pertained to neonatal abstinence syndrome diagnosis or management and were judged by the authors to be clinical trials, cohort studies, or case series. FINDINGS A total of 53 articles were included in the review, including 9 randomized clinical trials, 35 cohort studies, 1 cross-sectional study, and 8 case series-representing a total of 11 905 unique opioid-exposed mother-infant dyads. Thirteen studies were identified that evaluated established or novel neonatal abstinence syndrome assessment methods, such as brief neonatal abstinence syndrome assessment scales or novel objective physiologic measures to predict withdrawal. None of the new techniques that measure infant physiologic parameters are routinely used in clinical practice. The most substantial number of studies of neonatal abstinence syndrome management pertain to nonpharmacologic care-specifically, interventions that promote breastfeeding or encourage parents to room-in with their newborns. Although these nonpharmacologic interventions appear to decrease the need for pharmacologic treatment and result in shorter hospitalizations, the interventions are heterogeneous and there are no high-quality clinical trials to support them. Regarding pharmacologic interventions, only 5 randomized clinical trials with prespecified sample size calculations (4 infant, 1 maternal treatment) have been published. Each of these trials was small (from 26 to 131 participants) and tested different therapies, limiting the extent to which results can be aggregated. There is insufficient evidence to support an association between any diagnostic or treatment approach and differential neurodevelopmental outcomes among infants with neonatal abstinence syndrome. CONCLUSIONS AND RELEVANCE Evidence pertaining to the optimal diagnosis and treatment strategies for neonatal abstinence syndrome is based on small or low-quality studies that focus on intermediate outcomes, such as need for pharmacologic treatment or length of hospital stay. Clinical trials are needed to evaluate health and neurodevelopmental outcomes associated with objective diagnostic approaches as well as pharmacologic and nonpharmacologic treatment modalities.
Collapse
Affiliation(s)
- Elisha M Wachman
- Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts
- Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts
| | - Davida M Schiff
- Division of General Academic Pediatrics, Massachusetts General Hospital for Children and Harvard Medical School, Boston
| | - Michael Silverstein
- Grayken Center for Addiction, Boston Medical Center, Boston, Massachusetts
- Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts
| |
Collapse
|
40
|
Kaltenbach K, O'Grady KE, Heil SH, Salisbury AL, Coyle MG, Fischer G, Martin PR, Stine S, Jones HE. Prenatal exposure to methadone or buprenorphine: Early childhood developmental outcomes. Drug Alcohol Depend 2018; 185:40-49. [PMID: 29413437 PMCID: PMC5906792 DOI: 10.1016/j.drugalcdep.2017.11.030] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 11/17/2017] [Accepted: 11/24/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND Methadone and buprenorphine are recommended to treat opioid use disorders during pregnancy. However, the literature on the relationship between longer-term effects of prenatal exposure to these medications and childhood development is both spare and inconsistent. METHODS Participants were 96 children and their mothers who participated in MOTHER, a randomized controlled trial of opioid-agonist pharmacotherapy during pregnancy. The present study examined child growth parameters, cognition, language abilities, sensory processing, and temperament from 0 to 36 months of the child's life. Maternal perceptions of parenting stress, home environment, and addiction severity were also examined. RESULTS Tests of mean differences between children prenatally exposed to methadone vs. buprenorphine over the three-year period yielded 2/37 significant findings for children. Similarly, tests of mean differences between children treated for NAS relative to those not treated for NAS yielded 1/37 significant finding. Changes over time occurred for 27/37 child outcomes including expected child increases in weight, head and height, and overall gains in cognitive development, language abilities, sensory processing, and temperament. For mothers, significant changes over time in parenting stress (9/17 scales) suggested increasing difficulties with their children, notably seen in increasing parenting stress, but also an increasingly enriched home environment (4/7 scales) CONCLUSIONS: Findings strongly suggest no deleterious effects of buprenorphine relative to methadone or of treatment for NAS severity relative to not-treated for NAS on growth, cognitive development, language abilities, sensory processing, and temperament. Moreover, findings suggest that prenatal opioid agonist exposure is not deleterious to normal physical and mental development.
Collapse
Affiliation(s)
- Karol Kaltenbach
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA.
| | - Kevin E O'Grady
- Department of Psychology, University of Maryland, College Park, College Park, MD 20742, USA.
| | - Sarah H Heil
- Departments of Psychiatry and Psychology, University of Vermont, Burlington, VT, USA.
| | - Amy L Salisbury
- Brown Center for the Study of Children at Risk, Women and Infants' Hospital, Providence, RI, USA; Department of Pediatrics, The Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | - Mara G Coyle
- Department of Pediatrics, The Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | - Gabriele Fischer
- Department of Psychiatry and Psychotherapy, Medical University Vienna, Vienna, Austria.
| | - Peter R Martin
- Department of Psychiatry, Vanderbilt University, Nashville, TN, USA.
| | - Susan Stine
- Emeritus Professor of Psychiatry and Behavior Neurosciences, Wayne State University, Detroit, MI, USA.
| | - Hendrée E Jones
- UNC Horizons and Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA; Departments of Psychiatry and Behavioral Sciences and Obstetrics and Gynecology, School of Medicine, Johns Hopkins University, Baltimore, MD 21224, USA.
| |
Collapse
|
41
|
Mackay L, Abrahams R. Novel case of maternal and neonatal kratom dependence and withdrawal. Can Fam Physician 2018; 64:121-122. [PMID: 29449242 PMCID: PMC5964386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Lindsay Mackay
- Family physician who provides low-risk obstetric and addictions treatment in Vancouver, BC.
| | - Ronald Abrahams
- Clinical Professor in the Department of Family Practice at the University of British Columbia and Medical Director of Perinatal Addictions at the BC Women's Hospital and Health Centre in Vancouver
| |
Collapse
|
42
|
Milliren CE, Gupta M, Graham DA, Melvin P, Jorina M, Ozonoff A. Hospital Variation in Neonatal Abstinence Syndrome Incidence, Treatment Modalities, Resource Use, and Costs Across Pediatric Hospitals in the United States, 2013 to 2016. Hosp Pediatr 2018; 8:15-20. [PMID: 29263122 DOI: 10.1542/hpeds.2017-0077] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND The national incidence of neonatal abstinence syndrome (NAS) has increased with the opioid epidemic in the United States. The impact of pharmacologic treatment on hospital use is not well established. We examined the recent population of neonates with NAS admitted to pediatric hospitals, hospital variation in pharmacologic treatment, and the effect of treatment on resource use during neonatal hospitalization, including length of stay (LOS), readmission, and cost-of-living adjusted hospital costs. METHODS We included inpatients discharged between January 2013 and March 2016 from hospitals in the Pediatric Health Information System. We compared neonates with NAS to those without on demographic, socioeconomic, clinical characteristics and hospital resource use. We also compared neonates with NAS on these characteristics by pharmacologic treatment. RESULTS This analysis included 136 762 neonatal encounters from 23 hospitals. Of these, 2% had a diagnosis of NAS. Compared with other neonates, neonates with NAS had a longer LOS (18.7 vs 2.9 days; P = .004). Average costs per admission were 10 times higher for neonates with NAS ($37 584 vs $3536; P = .003). Of neonates with NAS, 70% were treated pharmacologically with wide variation in hospital rates of pharmacotherapy (range: 13%-90%). Pharmacologically-treated neonates with NAS experienced a longer LOS (22.0 vs 10.9 days; P = .004) than other neonates with NAS. Total costs for pharmacologically-treated neonates with NAS were over 2 times higher ($44 720 vs $20 708; P = .002) than neonates with NAS treated without pharmacotherapy. CONCLUSIONS Neonates with NAS, particularly those treated pharmacologically, have lengthier, more expensive hospital stays. Significant variation in pharmacologic treatment reflects opportunities for practice standardization and substantial reductions in resource use.
Collapse
Affiliation(s)
- Carly E Milliren
- Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston, Massachusetts; and
| | - Munish Gupta
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Dionne A Graham
- Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston, Massachusetts; and
| | - Patrice Melvin
- Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston, Massachusetts; and
| | - Maria Jorina
- Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston, Massachusetts; and
| | - Al Ozonoff
- Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston, Massachusetts; and
| |
Collapse
|
43
|
Abstract
OBJECTIVES Neonatal abstinence syndrome (NAS) is a growing problem and poses a significant burden on the health care system. The traditional Finnegan Neonatal Abstinence Scoring System (FNASS) assessment approach may lead to unnecessary opioid treatment of infants with NAS. We developed a novel assessment approach and describe its effect on the management of infants with NAS. METHODS We retrospectively compared treatment decisions of 50 consecutive opioid-exposed infants managed on the inpatient unit at the Yale New Haven Children's Hospital. All infants had FNASS scores recorded every 2 to 6 hours but were managed by using the Eat, Sleep, Console (ESC) assessment approach. Actual treatment decisions made by using the ESC approach were compared with predicted treatment decisions based on recorded FNASS scores. The primary outcome was postnatal treatment with morphine. RESULTS By using the ESC approach, 6 infants (12%) were treated with morphine compared with 31 infants (62%) predicted to be treated with morphine by using the FNASS approach (P < .001). The ESC approach started or increased morphine on 8 days (2.7%) compared with 76 days (25.7%) predicted by using the FNASS approach (P < .001). There were no readmissions or adverse events reported. CONCLUSIONS Infants managed by using the ESC approach were treated with morphine significantly less frequently than they would have been by using the FNASS approach. The ESC approach is an effective method for the management of infants with NAS that limits pharmacologic treatment and may lead to substantial reductions in length of stay.
Collapse
Affiliation(s)
- Matthew R Grossman
- Department of Pediatrics, School of Medicine, Yale University, New Haven, Connecticut; and
| | - Matthew J Lipshaw
- Department of Pediatrics, School of Medicine, Yale University, New Haven, Connecticut; and
| | - Rachel R Osborn
- Department of Pediatrics, School of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Adam K Berkwitt
- Department of Pediatrics, School of Medicine, Yale University, New Haven, Connecticut; and
| |
Collapse
|
44
|
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.
Collapse
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
| |
Collapse
|
45
|
Fallin-Bennett A, Ashford K. Tailoring a NICU-Based Tobacco Treatment Program for Mothers Who Are Dependent on Opioids. J Obstet Gynecol Neonatal Nurs 2017; 46:660-668. [PMID: 28754255 DOI: 10.1016/j.jogn.2017.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2017] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To collect formative information to design a tailored tobacco treatment intervention for women with newborns treated or evaluated for neonatal abstinence syndrome and to explore current tobacco use behaviors and facilitators and barriers to smoking cessation. DESIGN Qualitative descriptive study. SETTING An academic medical center in the southern United States. PARTICIPANTS Mothers (N = 11) of newborns who were treated or evaluated for neonatal abstinence syndrome at birth within the preceding 3 months. Women recruited were older than 18 years and reported opioid dependence and smoking during pregnancy. METHODS Participants took part in semistructured individual interviews that lasted approximately 1 hour. Interviews were professionally transcribed and analyzed in MAXQDA using content analysis. RESULTS Five themes emerged from the data: Strategizing to Reduce Risk, Desire to Quit Smoking in the Future, Holding on to Smoking While Working Through Recovery, Feeling Judged by Nurses, and Feeling Supported and Empowered by Nurses. Participants reported that they to reduce risk to their newborns by avoiding second- and thirdhand smoke exposure. Participants wanted to stop smoking but reported many barriers, including multiple life stressors compounded by their newborns' extended stays in the hospital. However, most participants described overall positive experiences and the support of health care providers. CONCLUSION Holistic tobacco treatment programs that incorporate stress relief and social support and are led by trusted health care providers have the potential to be effective to reduce smoking in new mothers with histories of opioid dependence disorders and smoking and whose newborns are in the NICU.
Collapse
|
46
|
Abstract
OBJECTIVE Standardized practices for the management of neonatal abstinence syndrome (NAS) are associated with shorter lengths of stay, but optimal protocols are not established. We sought to identify practice variations for newborns with in utero chronic opioid exposure among hospitals in the Better Outcomes Through Research for Newborns (BORN) network. METHODS Nursery site leaders completed a survey about hospitals' policies and practices regarding care for infants with chronic opioid exposure (≥3 weeks). RESULTS The 76 (80%) of 95 respondent hospitals were in 34 states, varied in size (<500 to >8000 births and <10 to >200 opioid-exposed infants per year), with most affiliated with academic centers (89%). Most (80%) had protocols for newborn drug exposure screening; 90% used risk-based approaches. Specimens included urine (85%), meconium (76%), and umbilical cords (10%). Of sites (88%) with NAS management protocols, 77% addressed medical management, 72% nursing care, 72% pharmacologic treatment, and 58% supportive care. Morphine was the most common first-line pharmacotherapy followed by methadone. Observation periods for opioid-exposed newborns varied; 57% observed short-acting opioid exposure for 2 to 3 days, while 30% observed for ≥5 days. For long-acting opioids, 71% observed for 4 to 5 days, 19% for 2 to 3 days, and 8% for ≥7 days. Observation for NAS occurred mostly in level 1 nurseries (86%); however, most (87%) transferred to NICUs when pharmacologic treatment was indicated. CONCLUSIONS Most BORN hospitals had protocols for the care of opioid-exposed infants, but policies varied widely and characterized areas of needed research. Identification of variation is the first step toward establishing best practice standards to improve care for this rapidly growing population.
Collapse
Affiliation(s)
- Debra L Bogen
- Division of General Academic Pediatrics, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pa.
| | - Bonny L Whalen
- Division of Pediatric Hospital Medicine, Department of Pediatrics, The Geisel School of Medicine at Dartmouth, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Laura R Kair
- Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, Iowa; Department of Pediatrics, University of California Davis Medical Center, Sacramento, Calif
| | - Mark Vining
- Division of General Pediatrics, Department of Pediatrics, University of Massachusetts Medical School, Worchester, Mass
| | | |
Collapse
|
47
|
Wachman EM, Hayes MJ, Sherva R, Brown MS, Shrestha H, Logan BA, Heller NA, Nielsen DA, Farrer LA. Association of maternal and infant variants in PNOC and COMT genes with neonatal abstinence syndrome severity. Am J Addict 2017; 26:42-49. [PMID: 27983768 PMCID: PMC5206487 DOI: 10.1111/ajad.12483] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 11/28/2016] [Accepted: 12/04/2016] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND AND OBJECTIVES There is significant variability in severity of neonatal abstinence syndrome (NAS) due to in utero opioid exposure. Our previous study identified single nucleotide polymorphisms (SNPs) in the prepronociceptin (PNOC) and catechol-O-methyltransferase (COMT) genes that were associated with differences in NAS outcomes. This study looks at the same SNPs in PNOC and COMT in an independent cohort in an attempt to replicate previous findings. METHODS For the replication cohort, full-term opioid-exposed newborns and their mothers (n = 113 pairs) were studied. A DNA sample was obtained and genotyped for five SNPs in the PNOC and COMT genes. The association of each SNP with NAS outcomes (length of hospitalization, need for pharmacologic treatment, and total opioid days) was evaluated, with an experiment-wise significance level set at α < .003 and point-wise level of α < .05. SNP associations in a combined cohort of n = 199 pairs (replication cohort plus 86 pairs previously reported), were also examined. RESULTS In the replication cohort, mothers with the COMT rs4680 G allele had infants with a reduced risk for treatment with two medications for NAS (adjusted OR = .5, p = .04), meeting point-wise significance. In the combined cohort, infants with the PNOC rs4732636 A allele had a reduced need for medication treatment (adjusted OR 2.0, p = .04); mothers with the PNOC rs351776 A allele had infants who were treated more often with two medications (adjusted OR 2.3, p = .004) with longer hospitalization by 3.3 days (p = .01). Mothers with the COMT rs740603 A allele had infants who were less often treated with any medication (adjusted OR .5, p = .02). Though all SNP associations all met point wise and clinical significance, they did not meet the experiment-wise significance threshold. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE We found differences in NAS outcomes depending on PNOC and COMT SNP genotype. This has important implications for identifying infants at risk for severe NAS who could benefit from tailored treatment regimens. Further testing in a larger sample is warranted. This has important implications for prenatal prediction and personalized treatment regimens for infants with NAS. (Am J Addict 2017;26:42-49).
Collapse
Affiliation(s)
- Elisha M Wachman
- Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts
| | - Marie J Hayes
- Graduate School of Biomedical Science and Engineering, University of Maine, Orono, Maine
| | - Richard Sherva
- Department of Biomedical Genetics, Boston University School of Medicine, Boston, Massachusetts
| | - Mark S Brown
- Department of Pediatrics, Eastern Maine Medical Center, Bangor, Maine
| | - Hira Shrestha
- Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts
| | - Beth A Logan
- Department of Transplant Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nicole A Heller
- Department of Psychology, Siena College, Loudonville, New York
| | - David A Nielsen
- Department of Psychiatry, Baylor College of Medicine, Houston, Texas
| | - Lindsay A Farrer
- Department of Biomedical Genetics, Boston University School of Medicine, Boston, Massachusetts
| |
Collapse
|
48
|
Affiliation(s)
- Karen McQueen
- From Lakehead University Schools of Nursing (K.M.) and Social Work (J.M.-O.), Thunder Bay, ON, Canada
| | - Jodie Murphy-Oikonen
- From Lakehead University Schools of Nursing (K.M.) and Social Work (J.M.-O.), Thunder Bay, ON, Canada
| |
Collapse
|
49
|
Abstract
Gestational substance exposure continues to be a significant problem. Neonates may be exposed to various substances including illicit drugs, prescription drugs, and other legal substances that are best not used during pregnancy because of their potential deleterious effects as possible teratogens or their potential to create dependence and thus withdrawal in the neonate. Screening the newborn for gestational substance exposure is important for both acute care and early intervention to promote the best possible long-term outcomes. This column provides insight into what is known about the extent of substance use by pregnant women, an overview of neonatal biologic matrices for drug testing, and a discussion of the legal implications of neonatal substance screening.
Collapse
|
50
|
D'Apolito K. Neonatal Abstinence Syndrome: A Growing Problem. Neonatal Netw 2016; 35:263-264. [PMID: 27636688 DOI: 10.1891/0730-0832.35.5.263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
|