Longitudinal Health Care Utilization of Medicaid-Insured Children with a History of Neonatal Abstinence Syndrome

A human iPSC-derived midbrain neural stem cell model of prenatal opioid exposure and withdrawal: A proof of concept study

A growing body of clinical literature has described neurodevelopmental delays in infants with chronic prenatal opioid exposure and withdrawal. Despite this, the mechanism of how opioids impact the developing brain remains unknown. Here, we developed an in vitro model of prenatal morphine exposure and withdrawal using healthy human induced pluripotent stem cell (iPSC)-derived midbrain neural progenitors in monolayer. To optimize our model, we identified that a longer neural induction and regional patterning period increases expression of canonical opioid receptors mu and kappa in midbrain neural progenitors compared to a shorter protocol (OPRM1, two-tailed t-test, p =  0.004; OPRK1, p =  0.0003). Next, we showed that the midbrain neural progenitors derived from a longer iPSC neural induction also have scant toll-like receptor 4 (TLR4) expression, a key player in neonatal opioid withdrawal syndrome pathophysiology. During morphine withdrawal, differentiating neural progenitors experience cyclic adenosine monophosphate overshoot compared to cell exposed to vehicle (p =  0.0496) and morphine exposure conditions (p, =  0.0136, 1-way ANOVA). Finally, we showed that morphine exposure and withdrawal alters proportions of differentiated progenitor cell fates (2-way ANOVA, F =  16.05, p <  0.0001). Chronic morphine exposure increased proportions of nestin positive progenitors (p =  0.0094), and decreased proportions of neuronal nuclear antigen positive neurons (NEUN) (p =  0.0047) compared to those exposed to vehicle. Morphine withdrawal decreased proportions of glial fibrillary acidic protein positive cells of astrocytic lineage (p =  0.044), and increased proportions of NEUN-positive neurons (p <  0.0001) compared to those exposed to morphine only. Applications of this paradigm include mechanistic studies underscoring neural progenitor cell fate commitments in early neurodevelopment during morphine exposure and withdrawal.

Call to Action: Standardizing Follow-Up Care for Infants Prenatally Exposed to Opioids

Between 2007 and 2017, rates of neonatal opioid withdrawal syndrome (NOWS) have drastically increased. Although current evidence suggests that chronic prenatal opioid exposure may result in adverse neurodevelopmental consequences, there is no standardized protocol for the follow-up care of affected patients. We call on the American Academy of Pediatrics to develop a standardized protocol for the follow-up care of infants prenatally exposed to opioids that also supports families and providers. More specifically, special consideration should be given to identifying and providing solutions to barriers of care for families, as well as for providers. Educating families on the importance of follow-up care would also be beneficial, as well as educating providers on how to address family barriers. Prioritizing and attending to this call to action will allow for improvement in practice and patient care over time and potentially reduce hospital readmission rates commonly associated with NOWS.

Recruitment and retention strategies to promote research engagement among caregivers and their children: A scoping review

Long-term health and developmental impact after in utero opioid and other substance exposures is unclear. There is an urgent need for well-designed, prospective, long-term observational studies. The HEALthy Brain and Child Development Study aims to address this need. It will require optimizing recruitment and retention of caregivers and young children in long-term research. Therefore, a scoping review of original research articles, indexed in the PubMed database and published in English between January 1, 2010, and November 23, 2023, was conducted on recruitment and retention strategies of caregiver-child (≤6 years old) dyads in observational, cohort studies. Among 2,902 titles/abstracts reviewed, 37 articles were found eligible. Of those, 29 (78%) addressed recruitment, and 18 (49%) addressed retention. Thirty-four (92%) articles focused on strategies for facilitating recruitment and/or retention, while 18 (49%) described potentially harmful approaches. Recruitment and retention facilitators included face-to-face and regular contact, establishing a relationship with study personnel, use of technology and social platforms, minimizing inconveniences, and promoting incentives. This review demonstrates that numerous factors can affect engagement of caregivers and their children in long-term cohort studies. Better understanding of these factors can inform researchers about optimal approaches to recruitment and retention of caregiver-child dyads in longitudinal research.

Clonidine as Monotherapy for Neonatal Opioid Withdrawal Syndrome: A Randomized Trial

OBJECTIVE

We sought to determine whether clonidine, a non-opioid α-2-adrenergic agonist, would effectively treat neonatal opioid withdrawal syndrome (NOWS).

METHODS

This was an intention-to-treat randomized clinical trial. Enrollment criteria included prenatal opioid exposure, age ≤7 days, gestational age ≥35 weeks, no other medical condition, and need for pharmacotherapy. Primary outcomes were length of treatment and neurobehavioral performance.

RESULTS

A total of 1107 patients were screened for enrollment (645 ineligible, 91 parents or staff unavailable, 216 declined, 155 consented). Of 155 infants, 120 required treatment and were randomized to receive oral clonidine (n = 60) at 1 µg/kg/dose or morphine (n = 60), 0.06 mg/kg/dose, every 3 hours. Infants with no improvement had their doses increased by 25% of the initial dose every 12 to 24 hours. Those without improvement by the fourth dose increase, received adjunct therapy. Length of treatment did not differ between morphine and clonidine, with median (95% confidence interval [CI]) days, respectively, of 15 (13-17) and 17 (15-19), P = .48. More clonidine-treated infants (45%) needed adjunct therapy versus 10% in the morphine group, adjusted odds ratio (95% CI) = 8.85 (2.87-27.31). After treatment completion, the NICU Network Neurobehavioral Scales summary scores did not differ between clonidine-treated and morphine-treated infants.

CONCLUSIONS

Length of pharmacologic treatment and final neurobehavioral performance were not significantly different between the clonidine- and morphine-treated groups. Clonidine appears to be an effective non-opioid medication to treat NOWS. Future studies are needed to determine the optimal clonidine dosage for a quicker response and obviation of adjunct therapy.

Trends in maternal opioid use: Statewide differences by sociodemographic characteristics in Florida from 2000 to 2019

BACKGROUND

Maternal opioid use (MOU) remains a public health concern. Studies have demonstrated significant increases in MOU, but estimates using ICD-10-CM or stratified by sociodemographic variables are limited.

OBJECTIVES

Using a statewide, population-based dataset of Florida resident deliveries from 2000 to 2019, we examined the trend of MOU by age, race/ethnicity, education level, and insurance.

METHODS

Florida administrative data was used to conduct a retrospective cohort study. MOU was identified using opioid-related hospital discharge diagnoses documented prenatally or at delivery. Maternal sociodemographic variables were obtained from Florida vital statistics. Joinpoint regression was used to identify statistically significant changes in the trends overall and stratified by sociodemographic variables. Results are presented as annual percentage changes (APC) and 95% confidence intervals.

RESULTS

Our sample included over 3.6 million Florida resident mothers; of which, MOU was identified in 1% (n = 22,828) of the sample. From 2000 to 2019, MOU increased over ten-fold from 8.7 to 94.7 per 10,000 live birth deliveries. MOU increased significantly from 2000 to 2011 (APC: 32.8; 95% CI: 29.4, 36.2), remained stable from 2011 to 2016, and decreased significantly from 2016 to 2019 (APC: 3.9; 95% CI: -6.6, -1.0). However, from 2016 to 2019, MOU increased among non-Hispanic Black mothers (APC: 9.2; 95% CI: 7.5, 11.0), and those ages 30-34 (APC: 2.9; 95% CI: 1.2, 4.6) and 35-39 (APC: 6.4; 95% CI: 4.3, 8.4).

CONCLUSIONS

Accurate prevalence estimates of MOU by sociodemographic factors are necessary to fully understand prevalence trends, describe the burden among sub-populations, and develop targeted interventions.

Health Care Needs and Costs for Children Exposed to Prenatal Substance Use to Adulthood

Importance

Children exposed to substance use during pregnancy have increased health needs but whether these are influenced by engagement in out-of-home care is uncertain.

Objective

To evaluate the association between substance use during pregnancy, out-of-home care and hospitalization utilization, and costs from birth up to age 20 years.

Design, Setting, and Participants

This was a retrospective cohort study using individual-linked population birth, hospital, and out-of-home care information of all liveborn infants from New South Wales, Australia, between 2001 and 2020 using longitudinal population-based linkage records from administrative databases. Substance use during pregnancy included newborns with neonatal abstinence syndrome (n = 5946) and intrauterine exposure to drugs of addiction (n = 1260) and other substances (eg, tobacco, alcohol, and illicit drugs or misused prescription drugs; n = 202 098). Children not exposed to substance use during pregnancy were those without known exposure to substance use during pregnancy (n = 1 611 351). Data were analyzed from July 2001 to December 2021.

Main Outcomes

Main outcomes were hospital readmission, length of stay, and cost burden associated with substance use during pregnancy from birth up to age 20 years. Outcomes were investigated using 2-part and Poisson regression models adjusted for sociodemographic characteristics. Mediation analysis was used to evaluate whether the association of substance use during pregnancy with risk of readmission was mediated through engagement with out-of-home care.

Results

Of the 1 820 655 live births, 935 807 (51.4%) were male. The mean (SD) age of mothers was 30.8 (5.5) years. Compared with children who were not exposed to substance use during pregnancy, those who were exposed incurred significantly higher birth hospital costs (adjusted mean difference, A$1585 per child [US$1 = A$1.51]; 95% CI, 1585-1586). If discharged alive, more children with exposure to substance use during pregnancy had at least 1 readmission (90 433/209 304 [43.4%] vs 616 425/1 611 351[38.3%]; adjusted relative risk [RR], 1.06; 95% CI, 1.06-1.07), most commonly for respiratory conditions (RR, 1.11; 95% CI, 1.09-1.12) and mental health/behavioral disorders (RR, 1.36; 95% CI, 1.33-1.41). Excess hospital costs associated with substance use during pregnancy were A$129.0 million in 2019 to 2020. Mediation analyses showed that any out-of-home care contact mediated the association between substance use during pregnancy and risk of inpatient readmission and lower health care cost (decreased by A$25.4 million). For children with neonatal abstinence syndrome, any out-of-home care contact mediated readmission risk by approximately 30%, from adjusted RR, 1.28; 95% CI, 1.19-1.35, to RR, 1.01; 95% CI, 0.98-1.02.

Conclusion and Relevance

Children who were exposed to substance use during pregnancy incurred more hospital costs than children who were not exposed up to 20 years of age, but this was reduced in association with any contact with out-of-home care. This provides insights into possible strategies for reducing health and financial burdens associated with exposure to substance use during pregnancy for children.

Health Services Use Among Children With Prenatal Substance Exposure or Neonatal Abstinence Syndrome

OBJECTIVE

Infants with prenatal substance exposure or neonatal abstinence syndrome (NAS) use health services more often than other children; however, little is known about their use of mental health services and psychotropic medication.

METHODS

The sample (N=1,004,085) consisted of infants born in 2016 in 38 states who were followed through the fifth year of life and enrolled each year in Medicaid or the Children's Health Insurance Program. Infants with prenatal substance exposure or NAS were identified with ICD-10 diagnosis codes; procedure and revenue codes documented their service use.

RESULTS

Rates of any mental health visit and of psychotropic medication use were higher among infants with prenatal substance exposure or NAS compared with infants without either condition; these patterns persisted during most years of the 5-year study.

CONCLUSIONS

Infants' elevated mental health services use through their first 5 years of life highlights the importance of early screening and subsequent engagement in school-based mental health interventions.

Cost of Care for Newborns With Neonatal Abstinence Syndrome in a State Medicaid Program

Importance

Neonatal abstinence syndrome (NAS) is a medical condition among neonates experiencing substance withdrawal due to the mother's substance use during pregnancy. While previous studies suggest that the overall incidence and annual costs of NAS are increasing, to date, the long-term costs have yet to be demonstrated in Medicaid populations.

Objective

To examine the demographic differences and long-term costs of care for neonates diagnosed with vs not diagnosed with NAS.

Design, Setting, and Participants

This cohort study used claims data from the Alabama Medicaid Agency for neonates born to Medicaid-eligible mothers between January 1, 2010, and December 31, 2020. Data were analyzed in June 2022.

Exposure

A diagnosis of NAS within 30 days of birth.

Main Outcomes and Measures

Rate of NAS by demographic and birth characteristics, long-term costs attributable to NAS status and demographic and birth characteristics, and distribution of this expenditure over the enrollment period.

Results

A total of 346 259 neonates with Medicaid eligibility were born during the study period (mean [SD] gestational age, 38.4 [2.2] weeks; 50.5%, male), 4027 (1.2%) of whom had an NAS diagnosis within 30 days of birth. A larger percentage of neonates with an NAS diagnosis were male (52.7%) than in the group without NAS (50.5%). Neonates with NAS also weighed less at birth (mean difference, -212.0 g; 95% CI, -231.1 to -192.8 g) and had older mothers (mean difference, 3.4 years; 95% CI, 2.6-4.2 years). An NAS diagnosis had an estimated additional cost of $17 921 (95% CI, $14 830-$21 012) over the enrollment period, and this cost was not evenly distributed over that period.

Conclusions and Relevance

In this cohort study of neonates born into the Alabama Medicaid population, those with an NAS diagnosis had a different demographic profile and a higher cost to state Medicaid agencies than those without NAS. These findings warrant further effort to reduce the occurrence of NAS.

Advances in the Care of Infants With Prenatal Opioid Exposure and Neonatal Opioid Withdrawal Syndrome

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.

Healthcare utilization among children with a history of neonatal opioid withdrawal syndrome: A matched cohort study

OBJECTIVES

Compare longitudinal healthcare utilization patterns in children with and without a history of neonatal opioid withdrawal syndrome (NOWS).

STUDY DESIGN

A retrospective matched cohort study was conducted using billing data extracted from between 2003 and 2016 in North Texas hospitals. The sample included 595 pediatric patients diagnosed with NOWS (i.e. exposed). The unexposed were patients not diagnosed with NOWS and matched 4:1 on sex, age at first encounter, and ethnicity to the exposed who received care during the same period. Multi-level regression models (accounting for clustered data structure of multiple visits per patient) compared number of hospitalizations, number of outpatient visits, number of emergency department (ED) visits, average length of stay, and healthcare expenditures across patients with and without NOWS.

RESULTS

Hospitalizations were significantly lower among exposed (Incidence Rate Ratio [IRR] = 0.58, 95 % Confidence Interval [CI] = 0.44-0.77) compared to unexposed. Outpatient visits, ED visits, and average length of stay was significantly higher among exposed compared to unexposed (IRR = 1.19, 95 % CI = 1.04-1.36; IRR = 1.22, 95 % CI = 1.04-1.42; IRR = 2.21, 95 % CI = 2.03-2.42, respectively). Overall healthcare expenditure was greater among exposed, as well as for patients with neurologic, endocrine, cardiac, mental disorders, respiratory, perinatal, infectious disease, eye, ear, digestive, congenital anomaly, and skin diagnoses.

CONCLUSIONS

Children with a diagnosis of NOWS have significantly higher healthcare expenditures, and with the exception of hospitalizations, higher healthcare utilization beyond the newborn visit. These findings suggest the needs for interventions for children with NOWS beyond the immediate neonatal period.