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Sealschott S, Pickler R, Fortney C, Bailey M, Loman B. Gut Microbiota and Symptom Expression and Severity in Neonatal Abstinence Syndrome. Biol Res Nurs 2024; 26:460-468. [PMID: 38528812 DOI: 10.1177/10998004241242102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
Problem: Neonatal abstinence syndrome (NAS) affecting neonates with fetal exposure to opioids, is defined by expression and severity of symptoms. The pathophysiology behind symptoms variability is lacking. The study aims were to examine (a) differences in gut microbiota of neonates with and without NAS, (b) the relationships between gut microbiota and symptom expression and NAS severity, and (c) the changes in the neonate gut microbiota diversity during the course of NAS treatment. Methods: A cross-sectional observational design was used to examine differences in microbiota and a longitudinal, repeated measures approach was used to determine relationships between gut microbiota and NAS symptoms. Symptom data were collected using the Finnegan Neonatal Abstinence Scoring Tool and the Neonatal Pain Agitation and Sedation Scale. Stool samples were collected for microbiome analyses with 16S rRNA microbiome sequencing. Results: Differences in alpha and beta diversity between neonates with and without NAS were seen. Relative abundance results revealed 18 taxa were different in neonates with NAS compared to neonates without NAS. No differences were found in alpha or beta diversity in neonates with NAS between enrollment and hospital discharge. There was increased abundance of Escherichia-Shigella and Bacteriodes genera related to higher symptom scores. Discussion: Differences in alpha and beta diversity between neonates with and without NAS may be due to differences in birth mode and type of feeding. The findings of specific increased bacteria related to increased symptoms in the neonates with NAS may also be influenced by birth mode and type of feeding.
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Affiliation(s)
| | - Rita Pickler
- The Ohio State University College of Nursing, Columbus, OH, USA
| | | | - Michael Bailey
- The Ohio State University College of Nursing, Columbus, OH, USA
- Center for Microbial Pathogenesis, Columbus, The Research Institute at Nationwide Children's Hospital, OH, USA
| | - Brett Loman
- University of Illinois Urbana-Champaign, Urbana, IL, USA
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Alur P, Holla I, Hussain N. Impact of sex, race, and social determinants of health on neonatal outcomes. Front Pediatr 2024; 12:1377195. [PMID: 38655274 PMCID: PMC11035752 DOI: 10.3389/fped.2024.1377195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 03/22/2024] [Indexed: 04/26/2024] Open
Abstract
Despite the global improvements in neonatal outcomes, mortality and morbidity rates among preterm infants are still unacceptably high. Therefore, it is crucial to thoroughly analyze the factors that affect these outcomes, including sex, race, and social determinants of health. By comprehending the influence of these factors, we can work towards reducing their impact and enhancing the quality of neonatal care. This review will summarize the available evidence on sex differences, racial differences, and social determinants of health related to neonates. This review will discuss sex differences in neonatal outcomes in part I and racial differences with social determinants of health in part II. Research has shown that sex differences begin to manifest in the early part of the pregnancy. Hence, we will explore this topic under two main categories: (1) Antenatal and (2) Postnatal sex differences. We will also discuss long-term outcome differences wherever the evidence is available. Multiple factors determine health outcomes during pregnancy and the newborn period. Apart from the genetic, biological, and sex-based differences that influence fetal and neonatal outcomes, racial and social factors influence the health and well-being of developing humans. Race categorizes humans based on shared physical or social qualities into groups generally considered distinct within a given society. Social determinants of health (SDOH) are the non-medical factors that influence health outcomes. These factors can include a person's living conditions, access to healthy food, education, employment status, income level, and social support. Understanding these factors is essential in developing strategies to improve overall health outcomes in communities.
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Affiliation(s)
- Pradeep Alur
- Penn State College of Medicine, Hampden Medical Center, Enola, PA, United States
| | - Ira Holla
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, United States
| | - Naveed Hussain
- Department of Pediatrics, Connecticut Children’s, Hartford, CT, United States
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Madurai NK, Jantzie LL, Yen E. Sex differences in neonatal outcomes following prenatal opioid exposure. Front Pediatr 2024; 12:1357970. [PMID: 38577634 PMCID: PMC10991792 DOI: 10.3389/fped.2024.1357970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 03/04/2024] [Indexed: 04/06/2024] Open
Abstract
The impact of the opioid epidemic on pregnant people and children is a growing public health crisis. Understanding how opioids affect the developing brain during pregnancy and postnatally remains a critical area of investigation. Biological sex plays a crucial role in all physiologic processes, with the potential for a significant impact on neonatal outcomes, including those infants with opioid exposure. Here, we aim to explore current literature on the effect of sex on neonatal outcomes following prenatal opioid exposure. Sex differences in adults with opioid use disorder have been well studied, including increased mortality among males and higher rates of psychiatric comorbidities and likelihood of relapse in females. However, such differences are not yet well understood in neonates. Emerging clinical data suggest sex-specific effects in infants with prenatal opioid exposure on the expression of genes related to feeding regulation and reward signaling pathways. Increased susceptibility to white matter injury has also been noted in female infants following prenatal opioid exposure. Understanding the impact of sex as a biological variable on neonatal outcomes following prenatal opioid exposure is paramount to improving the health and well-being of infants, children, and adults impacted by the opioid epidemic.
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Affiliation(s)
- Nethra K. Madurai
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Lauren L. Jantzie
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Neurodevelopmental Medicine, Phelps Center for Cerebral Palsy and Neurodevelopmental Medicine, Kennedy Krieger Institute, Baltimore, MD, United States
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Elizabeth Yen
- Mother Infant Research Institute (MIRI), Tufts Medical Center, Boston, MA, United States
- Division of Newborn Medicine, Tufts Medicine Pediatrics-Boston Children's, Boston, MA, United States
- Department of Pediatrics, Tufts University School of Medicine, Boston, MA, United States
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Tobacyk J, Parks BJ, Salazar P, Coward LU, Berquist MD, Gorman GS, Brents LK. Interaction between buprenorphine and norbuprenorphine in neonatal opioid withdrawal syndrome. Drug Alcohol Depend 2023; 249:110832. [PMID: 37385117 PMCID: PMC10573081 DOI: 10.1016/j.drugalcdep.2023.110832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 06/09/2023] [Accepted: 06/12/2023] [Indexed: 07/01/2023]
Abstract
Buprenorphine (BUP) is the preferred treatment for opioid use disorder during pregnancy but can cause neonatal opioid withdrawal syndrome (NOWS). Norbuprenorphine (NorBUP), an active metabolite of BUP, is implicated in BUP-associated NOWS. We hypothesized that BUP, a low-efficacy agonist of mu opioid receptors, will not antagonize NorBUP, a high-efficacy agonist of mu opioid receptors, in producing NOWS. To test this hypothesis, we treated pregnant Long-Evans rats with BUP (0, 0.01, 0.1 or 1mg/kg/day) ± NorBUP (1mg/kg/day) from gestation day 9 until pup delivery, and tested pups for opioid dependence using our established NOWS model. We used LC-MS-MS to quantify brain concentrations of BUP, NorBUP, and their glucuronide conjugates. BUP had little effect on NorBUP-induced NOWS, with the exception of 1mg/kg/day BUP significantly increasing NorBUP-induced NOWS by 58% in females. BUP and NorBUP brain concentrations predicted NOWS in multiple linear regression models. Interestingly, NorBUP contributed more to NOWS in females (βNorBUP = 51.34, p = 0.0001) than in males (βNorBUP = 19.21, P = 0.093), while BUP was similar for females (βBUP = 10.62, P = 0.0017) and males (βBUP = 11.38, P = 0.009). We are the first to report that NorBUP induces NOWS in the presence of BUP and it is more influential in females than males in the contribution of NorBUP to BUP-associated NOWS. These findings suggest that females are more susceptible to NorBUP-induced NOWS, and that treatment strategies that reduce prenatal NorBUP exposure may be more effective for females than males.
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Affiliation(s)
- Julia Tobacyk
- Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Mail Slot 611, Little Rock, AR72205, USA
| | - Brian J Parks
- Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Mail Slot 611, Little Rock, AR72205, USA
| | - Paloma Salazar
- Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Mail Slot 611, Little Rock, AR72205, USA
| | - Lori U Coward
- Department of Pharmaceutical Sciences in the McWhorter School of Pharmacy at Samford University, 800 Lakeshore Dr, Birmingham, AL35229, USA
| | - Michael D Berquist
- Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Mail Slot 611, Little Rock, AR72205, USA
| | - Gregory S Gorman
- Department of Pharmaceutical Sciences in the McWhorter School of Pharmacy at Samford University, 800 Lakeshore Dr, Birmingham, AL35229, USA
| | - Lisa K Brents
- Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Mail Slot 611, Little Rock, AR72205, USA.
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Predictors of pharmacologic therapy for neonatal opioid withdrawal syndrome: a retrospective analysis of a statewide database. J Perinatol 2021; 41:1381-1388. [PMID: 33608626 DOI: 10.1038/s41372-021-00969-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/13/2021] [Accepted: 01/27/2021] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Identify factors associated with the need for pharmacologic therapy (PT) among opioid exposed newborn (OENs). STUDY DESIGN Retrospective analysis of a statewide database of OENs from 2017 through 2019. Multivariable mixed-effects logistic regression modeled the association of maternal characteristics, infant characteristics, and family engagement practices on the receipt of PT. RESULTS Of 2098 OENs, 44.8% required PT for NOWS. Higher odds of PT were associated with in-utero exposure to medication treatment for opioid use disorder (MOUD) and non-prescribed opioids in addition to MOUD; nicotine, benzodiazepines, SSRIs; male; out-born infants and mother's ineligibility to provide breast-milk. Lower odds were associated with increasing birth year, skin-to-skin (STS) care, and rooming-in. CONCLUSION Male, out-born infants exposed to MOUD with additional non-prescribed opioids, nicotine, benzodiazepines and SSSRIs with mothers ineligible to provide breast-milk were more likely to require PT, while modifiable care practices including STS care, and rooming-in decreased the likelihood of PT.
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Goetzl L, Thompson-Felix T, Darbinian N, Merabova N, Merali S, Merali C, Sanserino K, Tatevosian T, Fant B, Wimmer ME. Novel biomarkers to assess in utero effects of maternal opioid use: First steps toward understanding short- and long-term neurodevelopmental sequelae. GENES BRAIN AND BEHAVIOR 2019; 18:e12583. [PMID: 31119847 DOI: 10.1111/gbb.12583] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 05/17/2019] [Accepted: 05/21/2019] [Indexed: 12/24/2022]
Abstract
Maternal opioid use disorder is common, resulting in significant neonatal morbidity and cost. Currently, it is not possible to predict which opioid-exposed newborns will require pharmacotherapy for neonatal abstinence syndrome. Further, little is known regarding the effects of maternal opioid use disorder on the developing human brain. We hypothesized that novel methodologies utilizing fetal central nervous system-derived extracellular vesicles isolated from maternal blood can address these gaps in knowledge. Plasma from opioid users and controls between 9 and 21 weeks was precipitated and extracellular vesicles were isolated. Mu opioid and cannabinoid receptor levels were quantified. Label-free proteomics studies and unbiased small RNA next generation sequencing was performed in paired fetal brain tissue. Maternal opioid use disorder increased mu opioid receptor protein levels in extracellular vesicles independent of opioid equivalent dose. Moreover, cannabinoid receptor levels in extracellular vesicles were upregulated with opioid exposure indicating cross talk with endocannabinoids. Maternal opioid use disorder was associated with significant changes in extracellular vesicle protein cargo and fetal brain micro RNA expression, especially in male fetuses. Many of the altered cargo molecules and micro RNAs identified are associated with adverse clinical neurodevelopmental outcomes. Our data suggest that assays relying on extracellular vesicles isolated from maternal blood extracellular vesicles may provide information regarding fetal response to opioids in the setting of maternal opioid use disorder. Prospective clinical studies are needed to evaluate the association between extracellular vesicle biomarkers, risk of neonatal abstinence syndrome and neurodevelopmental outcomes.
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Affiliation(s)
- Laura Goetzl
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Sciences Center, Houston, Texas
| | - Tara Thompson-Felix
- Department of Psychiatry and Behavioral Science, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Nune Darbinian
- Shriners Pediatric Research Center, Center for Neural Repair and Rehabilitation, Temple University, Philadelphia, Pennsylvania
| | - Nana Merabova
- Shriners Pediatric Research Center, Center for Neural Repair and Rehabilitation, Temple University, Philadelphia, Pennsylvania
| | - Salim Merali
- School of Pharmacy, Temple University, Philadelphia, Pennsylvania
| | - Carmen Merali
- School of Pharmacy, Temple University, Philadelphia, Pennsylvania
| | - Kathryne Sanserino
- Department of Obstetrics & Gynecology, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Tamara Tatevosian
- Shriners Pediatric Research Center, Center for Neural Repair and Rehabilitation, Temple University, Philadelphia, Pennsylvania
| | - Bruno Fant
- Department of Psychiatry, Center for Neurobiology and Behavior, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mathieu E Wimmer
- Department of Psychology, Temple University, Philadelphia, Pennsylvania
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7
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Griffin BA, Caperton CO, Russell LN, Cabanlong CV, Wilson CD, Urquhart KR, Martins BS, Zita MD, Patton AL, Alund AW, Owens SM, Fantegrossi WE, Moran JH, Brents LK. In Utero Exposure to Norbuprenorphine, a Major Metabolite of Buprenorphine, Induces Fetal Opioid Dependence and Leads to Neonatal Opioid Withdrawal Syndrome. J Pharmacol Exp Ther 2019; 370:9-17. [PMID: 31028107 DOI: 10.1124/jpet.118.254219] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 04/25/2019] [Indexed: 11/22/2022] Open
Abstract
Buprenorphine is the preferred treatment of opioid use disorder during pregnancy but can cause fetal opioid dependence and neonatal opioid withdrawal syndrome (NOWS). Notably, withdrawal severity is independent of maternal buprenorphine dose, suggesting that interindividual variance in pharmacokinetics may influence risk and severity of NOWS. Using a rat model of NOWS, we tested the hypothesis that clinically relevant doses of the active metabolite norbuprenorphine (NorBUP) can induce in utero opioid dependence, manifested as naltrexone-precipitated withdrawal signs in the neonate. Pregnant Long-Evans rats were implanted with 14-day osmotic minipumps containing vehicle, morphine (positive control), or NorBUP (0.3-10 mg/kg per day) on gestation day 9. By 12 hours post-delivery, an intraperitoneal injection of the opioid antagonist naltrexone (1 or 10 mg/kg) or saline was administered to pups. Precipitated withdrawal signs were graded by raters blinded to treatment conditions. In a separate group, NorBUP concentrations in maternal and fetal blood and brain on gestation day 20 were determined by liquid chromatography-tandem mass spectrometry. Steady-state maternal blood concentrations of NorBUP in dams infused with 1 or 3 mg/kg per day were comparable to values reported in pregnant humans treated with buprenorphine (1.0 and 9.6 ng/ml, respectively), suggesting a clinically relevant dosing regimen. At these doses, NorBUP increased withdrawal severity in the neonate as shown by an evaluation of 10 withdrawal indicators. These findings support the possibility that NorBUP contributes to fetal opioid dependence and NOWS following maternal buprenorphine treatment during pregnancy.
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Affiliation(s)
- Bryce A Griffin
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, Arkansas (B.A.G.); Departments of Pharmacology and Toxicology (C.O.C., L.N.R., C.V.C., C.D.W., K.R.U., S.M.O., W.E.F., J.H.M., L.K.B.), Psychiatry (B.S.M.), and Microbiology and Immunology (M.D.Z.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and PinPoint Testing, LLC, Little Rock, Arkansas (A.L.P., A.W.A., J.H.M.)
| | - Caitlin O Caperton
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, Arkansas (B.A.G.); Departments of Pharmacology and Toxicology (C.O.C., L.N.R., C.V.C., C.D.W., K.R.U., S.M.O., W.E.F., J.H.M., L.K.B.), Psychiatry (B.S.M.), and Microbiology and Immunology (M.D.Z.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and PinPoint Testing, LLC, Little Rock, Arkansas (A.L.P., A.W.A., J.H.M.)
| | - Lauren N Russell
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, Arkansas (B.A.G.); Departments of Pharmacology and Toxicology (C.O.C., L.N.R., C.V.C., C.D.W., K.R.U., S.M.O., W.E.F., J.H.M., L.K.B.), Psychiatry (B.S.M.), and Microbiology and Immunology (M.D.Z.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and PinPoint Testing, LLC, Little Rock, Arkansas (A.L.P., A.W.A., J.H.M.)
| | - Christian V Cabanlong
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, Arkansas (B.A.G.); Departments of Pharmacology and Toxicology (C.O.C., L.N.R., C.V.C., C.D.W., K.R.U., S.M.O., W.E.F., J.H.M., L.K.B.), Psychiatry (B.S.M.), and Microbiology and Immunology (M.D.Z.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and PinPoint Testing, LLC, Little Rock, Arkansas (A.L.P., A.W.A., J.H.M.)
| | - Catheryn D Wilson
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, Arkansas (B.A.G.); Departments of Pharmacology and Toxicology (C.O.C., L.N.R., C.V.C., C.D.W., K.R.U., S.M.O., W.E.F., J.H.M., L.K.B.), Psychiatry (B.S.M.), and Microbiology and Immunology (M.D.Z.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and PinPoint Testing, LLC, Little Rock, Arkansas (A.L.P., A.W.A., J.H.M.)
| | - Kyle R Urquhart
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, Arkansas (B.A.G.); Departments of Pharmacology and Toxicology (C.O.C., L.N.R., C.V.C., C.D.W., K.R.U., S.M.O., W.E.F., J.H.M., L.K.B.), Psychiatry (B.S.M.), and Microbiology and Immunology (M.D.Z.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and PinPoint Testing, LLC, Little Rock, Arkansas (A.L.P., A.W.A., J.H.M.)
| | - Bradford S Martins
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, Arkansas (B.A.G.); Departments of Pharmacology and Toxicology (C.O.C., L.N.R., C.V.C., C.D.W., K.R.U., S.M.O., W.E.F., J.H.M., L.K.B.), Psychiatry (B.S.M.), and Microbiology and Immunology (M.D.Z.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and PinPoint Testing, LLC, Little Rock, Arkansas (A.L.P., A.W.A., J.H.M.)
| | - Marcelle Dina Zita
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, Arkansas (B.A.G.); Departments of Pharmacology and Toxicology (C.O.C., L.N.R., C.V.C., C.D.W., K.R.U., S.M.O., W.E.F., J.H.M., L.K.B.), Psychiatry (B.S.M.), and Microbiology and Immunology (M.D.Z.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and PinPoint Testing, LLC, Little Rock, Arkansas (A.L.P., A.W.A., J.H.M.)
| | - Amy L Patton
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, Arkansas (B.A.G.); Departments of Pharmacology and Toxicology (C.O.C., L.N.R., C.V.C., C.D.W., K.R.U., S.M.O., W.E.F., J.H.M., L.K.B.), Psychiatry (B.S.M.), and Microbiology and Immunology (M.D.Z.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and PinPoint Testing, LLC, Little Rock, Arkansas (A.L.P., A.W.A., J.H.M.)
| | - Alexander W Alund
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, Arkansas (B.A.G.); Departments of Pharmacology and Toxicology (C.O.C., L.N.R., C.V.C., C.D.W., K.R.U., S.M.O., W.E.F., J.H.M., L.K.B.), Psychiatry (B.S.M.), and Microbiology and Immunology (M.D.Z.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and PinPoint Testing, LLC, Little Rock, Arkansas (A.L.P., A.W.A., J.H.M.)
| | - S Michael Owens
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, Arkansas (B.A.G.); Departments of Pharmacology and Toxicology (C.O.C., L.N.R., C.V.C., C.D.W., K.R.U., S.M.O., W.E.F., J.H.M., L.K.B.), Psychiatry (B.S.M.), and Microbiology and Immunology (M.D.Z.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and PinPoint Testing, LLC, Little Rock, Arkansas (A.L.P., A.W.A., J.H.M.)
| | - William E Fantegrossi
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, Arkansas (B.A.G.); Departments of Pharmacology and Toxicology (C.O.C., L.N.R., C.V.C., C.D.W., K.R.U., S.M.O., W.E.F., J.H.M., L.K.B.), Psychiatry (B.S.M.), and Microbiology and Immunology (M.D.Z.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and PinPoint Testing, LLC, Little Rock, Arkansas (A.L.P., A.W.A., J.H.M.)
| | - Jeffery H Moran
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, Arkansas (B.A.G.); Departments of Pharmacology and Toxicology (C.O.C., L.N.R., C.V.C., C.D.W., K.R.U., S.M.O., W.E.F., J.H.M., L.K.B.), Psychiatry (B.S.M.), and Microbiology and Immunology (M.D.Z.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and PinPoint Testing, LLC, Little Rock, Arkansas (A.L.P., A.W.A., J.H.M.)
| | - Lisa K Brents
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, Arkansas (B.A.G.); Departments of Pharmacology and Toxicology (C.O.C., L.N.R., C.V.C., C.D.W., K.R.U., S.M.O., W.E.F., J.H.M., L.K.B.), Psychiatry (B.S.M.), and Microbiology and Immunology (M.D.Z.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and PinPoint Testing, LLC, Little Rock, Arkansas (A.L.P., A.W.A., J.H.M.)
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8
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Charles MK, Cooper WO, Jansson LM, Dudley J, Slaughter JC, Patrick SW. Male Sex Associated With Increased Risk of Neonatal Abstinence Syndrome. Hosp Pediatr 2017; 7:328-334. [PMID: 28465360 PMCID: PMC5519405 DOI: 10.1542/hpeds.2016-0218] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Neonatal abstinence syndrome (NAS) is a postnatal opioid withdrawal syndrome. Factors associated with development of the syndrome are poorly understood; however, infant sex may influence the risk of NAS. Our objective was to determine if infant sex was associated with the development or severity of the syndrome in a large population-based cohort. METHODS This retrospective cohort study used vital statistics and prescription, outpatient, and inpatient administrative data for mothers and infants enrolled in the Tennessee Medicaid program between 2009 and 2011. Multivariable logistic regression models were used to evaluate the association between male sex and diagnosis of NAS, accounting for potential demographic and clinical confounders. NAS severity, as evidenced by hospital length of stay, was modeled by using negative binomial regression. RESULTS Of 102 695 infants, 927 infants were diagnosed with NAS (484 male subjects and 443 female subjects). Adjustments were made for the following: maternal age, race, and education; maternal hepatitis C infection, anxiety, or depression; in utero exposure to selective serotonin reuptake inhibitors and cigarettes; infant birth weight, small for gestational age, and year; and the interaction between opioid type and opioid amount. Male infants were more likely than female infants to be diagnosed with NAS (adjusted odds ratio, 1.18 [95% confidence interval, 1.05-1.33]) and NAS requiring treatment (adjusted odds ratio, 1.24 [95% confidence interval, 1.04-1.47]). However, there was no sex-based difference in severity for those diagnosed with NAS. CONCLUSIONS Treatment of NAS should be tailored to an infant's individual risk for the syndrome. Clinicians should be mindful that male sex is an important risk factor in the diagnosis of NAS.
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Affiliation(s)
| | - William O Cooper
- Vanderbilt University School of Medicine, Nashville, Tennessee
- Departments of Pediatrics
- Health Policy, and
- Vanderbilt Center for Health Services Research, Nashville, Tennessee
| | - Lauren M Jansson
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | | | - James C Slaughter
- Vanderbilt University School of Medicine, Nashville, Tennessee
- Biostatistics, Vanderbilt University, Nashville, Tennessee
| | - Stephen W Patrick
- Vanderbilt University School of Medicine, Nashville, Tennessee;
- Departments of Pediatrics
- Health Policy, and
- Vanderbilt Center for Health Services Research, Nashville, Tennessee
- Mildred Stahlman Division of Neonatology, Vanderbilt University, Nashville, Tennessee
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9
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Shah D, Brown S, Hagemeier N, Zheng S, Kyle A, Pryor J, Dankhara N, Singh P. Predictors of neonatal abstinence syndrome in buprenorphine exposed newborn: can cord blood buprenorphine metabolite levels help? SPRINGERPLUS 2016; 5:854. [PMID: 27386303 PMCID: PMC4919189 DOI: 10.1186/s40064-016-2576-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 06/15/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Buprenorphine is a semi-synthetic opioid used for the treatment of opioid dependence. Opioid use, including buprenorphine, has been increasing in recent years, in the general population and in pregnant women. Consequently, there has been a rise in frequency of neonatal abstinence syndrome (NAS), associated with buprenorphine use during pregnancy. The purpose of this study was to investigate correlations between buprenorphine and buprenorphine-metabolite concentrations in cord blood and onset of NAS in buprenorphine exposed newborns. METHODS Nineteen (19) newborns who met inclusion criteria were followed after birth until discharge in a double-blind non-intervention study, after maternal consent. Cord blood and tissue samples were collected and analyzed by liquid chromatography-mass spectrometry (LC-MS) for buprenorphine and metabolites. Simple and multiple logistic regressions were used to examine relationships between buprenorphine and buprenorphine metabolite concentrations in cord blood and onset of NAS, need for morphine therapy, and length of stay. RESULTS Each increase in 5 ng/ml level of norbuprenorphine in cord blood increases odds of requiring treatment by morphine 2.5 times. Each increase in 5 ng/ml of buprenorphine-glucuronide decreases odds of receiving morphine by 57.7 %. Along with concentration of buprenorphine metabolites, birth weight and gestational age also play important roles, but not maternal buprenorphine dose. CONCLUSIONS LC-MS analysis of cord blood concentrations of buprenorphine and metabolites is an effective way to examine drug and metabolite levels in the infant at birth. Cord blood concentrations of the active norbuprenorphine metabolite and the inactive buprenorphine-glucuronide metabolite show promise in predicting necessity of treatment of NAS. These finding have implications in improving patient care and reducing healthcare costs if confirmed in a larger sample.
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Affiliation(s)
- Darshan Shah
- />Department of Pediatrics, Quillen College of Medicine, East Tennessee State University, Johnson City, TN USA
| | - Stacy Brown
- />Department of Pharmaceutical Sciences, Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN USA
| | - Nick Hagemeier
- />Department of Pharmacy Practice, Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN USA
| | - Shimin Zheng
- />College of Public Health, East Tennessee State University, Johnson City, TN USA
| | - Amy Kyle
- />Department of Pharmaceutical Sciences, Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN USA
| | - Jason Pryor
- />Neonatal Perinatal Medicine, Vanderbilt University Medical Center/Monroe Carell Children’s Hospital, 2200 Children’s Way, Nashville, TN 37232 USA
| | - Nilesh Dankhara
- />Department of Pediatrics, Quillen College of Medicine, East Tennessee State University, Johnson City, TN USA
| | - Piyuesh Singh
- />Department of Pediatrics, Quillen College of Medicine, East Tennessee State University, Johnson City, TN USA
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10
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DiPietro JA, Voegtline KM. The gestational foundation of sex differences in development and vulnerability. Neuroscience 2015; 342:4-20. [PMID: 26232714 DOI: 10.1016/j.neuroscience.2015.07.068] [Citation(s) in RCA: 176] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 07/22/2015] [Accepted: 07/24/2015] [Indexed: 01/06/2023]
Abstract
Despite long-standing interest in the role of sex on human development, the functional consequences of fetal sex on early development are not well-understood. Here we explore the gestational origins of sex as a moderator of development. In accordance with the focus of this special issue, we examine evidence for a sex differential in vulnerability to prenatal and perinatal risks. Exposures evaluated include those present in the external environment (e.g., lead, pesticides), those introduced by maternal behaviors (e.g., alcohol, opioid use), and those resulting from an adverse intrauterine environment (e.g., preterm birth). We also provide current knowledge on the degree to which sex differences in fetal neurobehavioral development (i.e., cardiac and motor patterns) are present prior to birth. Also considered are contemporaneous and persistent sex of fetus effects on the pregnant woman. Converging evidence confirms that infant and early childhood developmental outcomes of male fetuses exposed to prenatal and perinatal adversities are more highly impaired than those of female fetuses. In certain circumstances, male fetuses are both more frequently exposed to early adversities and more affected by them when exposed than are female fetuses. The mechanisms through which biological sex imparts vulnerability or protection on the developing nervous system are largely unknown. We consider models that implicate variation in maturation, placental functioning, and the neuroendocrine milieu as potential contributors. Many studies use sex as a control variable, some analyze and report main effects for sex, but those that report interaction terms for sex are scarce. As a result, the true scope of sex differences in vulnerability is unknown.
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Affiliation(s)
- J A DiPietro
- Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - K M Voegtline
- Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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11
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Patrick SW, Dudley J, Martin PR, Harrell FE, Warren MD, Hartmann KE, Ely EW, Grijalva CG, Cooper WO. Prescription opioid epidemic and infant outcomes. Pediatrics 2015; 135:842-50. [PMID: 25869370 PMCID: PMC4411781 DOI: 10.1542/peds.2014-3299] [Citation(s) in RCA: 201] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2015] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Although opioid pain relievers are commonly prescribed in pregnancy, their association with neonatal outcomes is poorly described. Our objectives were to identify neonatal complications associated with antenatal opioid pain reliever exposure and to establish predictors of neonatal abstinence syndrome (NAS). METHODS We used prescription and administrative data linked to vital statistics for mothers and infants enrolled in the Tennessee Medicaid program between 2009 and 2011. A random sample of NAS cases was validated by medical record review. The association of antenatal exposures with NAS was evaluated by using multivariable logistic regression, controlling for maternal and infant characteristics. RESULTS Of 112,029 pregnant women, 31,354 (28%) filled ≥ 1 opioid prescription. Women prescribed opioid pain relievers were more likely than those not prescribed opioids (P < .001) to have depression (5.3% vs 2.7%), anxiety disorder (4.3% vs 1.6%) and to smoke tobacco (41.8% vs 25.8%). Infants with NAS and opioid-exposed infants were more likely than unexposed infants to be born at a low birth weight (21.2% vs 11.8% vs 9.9%; P < .001). In a multivariable model, higher cumulative opioid exposure for short-acting preparations (P < .001), opioid type (P < .001), number of daily cigarettes smoked (P < .001), and selective serotonin reuptake inhibitor use (odds ratio: 2.08 [95% confidence interval: 1.67-2.60]) were associated with greater risk of developing NAS. CONCLUSIONS Prescription opioid use in pregnancy is common and strongly associated with neonatal complications. Antenatal cumulative prescription opioid exposure, opioid type, tobacco use, and selective serotonin reuptake inhibitor use increase the risk of NAS.
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Affiliation(s)
- Stephen W Patrick
- Departments of Pediatrics, Mildred Stahlman Division of Neonatology, Vanderbilt University, Nashville, Tennessee; Vanderbilt Center for Health Services Research, Nashville, Tennessee; Health Policy,
| | | | | | | | | | - Katherine E Hartmann
- Vanderbilt Center for Health Services Research, Nashville, Tennessee; Obstetrics and Gynecology, and
| | - E Wesley Ely
- Vanderbilt Center for Health Services Research, Nashville, Tennessee; Medicine, Vanderbilt University, Nashville, Tennessee; Veteran's Affairs, Tennessee Valley Geriatric Research Education Clinical Center, Nashville, Tennessee
| | - Carlos G Grijalva
- Vanderbilt Center for Health Services Research, Nashville, Tennessee; Health Policy, Veteran's Affairs, Tennessee Valley Geriatric Research Education Clinical Center, Nashville, Tennessee
| | - William O Cooper
- Departments of Pediatrics, Vanderbilt Center for Health Services Research, Nashville, Tennessee; Health Policy
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12
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Gaalema DE, Heil SH, Badger GJ, Metayer JS, Johnston AM. Time to initiation of treatment for neonatal abstinence syndrome in neonates exposed in utero to buprenorphine or methadone. Drug Alcohol Depend 2013; 133:266-9. [PMID: 23845658 PMCID: PMC3786061 DOI: 10.1016/j.drugalcdep.2013.06.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Revised: 06/06/2013] [Accepted: 06/11/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND The recommended standard of care calls for treating opioid-dependent pregnant women with methadone and observing neonates exposed in utero for five to seven postnatal days to see if treatment for neonatal abstinence syndrome (NAS) is needed. Data from a large multi-site randomized clinical trial comparing buprenorphine vs. methadone for the treatment of opioid dependence during pregnancy suggest buprenorphine-exposed neonates had less severe NAS, but may require pharmacologic treatment for NAS later than methadone-exposed neonates. The present study examined whether time to pharmacologic treatment initiation differed in a relatively large non-blinded clinical sample of buprenorphine- vs. methadone-exposed neonates treated for NAS. METHODS Medical records for 75 neonates exposed to buprenorphine (n=47) or methadone (n=28) in utero who required treatment for NAS were examined. Time elapsed between birth and initiation of pharmacologic treatment was calculated for each neonate and time to treatment initiation compared between groups. RESULTS Median time to treatment initiation (hours:minutes, IQR) was significantly later in buprenorphine- vs. methadone-exposed neonates (71:02, 44:21-96:27 vs. 34:12, 21:00-55:41, respectively, p<.001). Estimates of mean time to treatment initiation from parametric analyses that adjusted for maternal and neonatal characteristics were very similar (73:10 (95% CI: 61:00-87:18) vs. 42:36 (95% CI: 33:06-53:30), respectively, p=.0005). This difference was not dependent on maternal age or neonatal sex, gestational age, or birth weight. CONCLUSIONS These findings confirm results from randomized clinical trials, adding generality to the observation that buprenorphine-exposed neonates require treatment significantly later than methadone-exposed neonates.
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Affiliation(s)
- Diann E. Gaalema
- University of Vermont, Department of Psychiatry, 1 South Prospect Street UHC, Burlington, VT 05401,University of Vermont, Department of Psychology, 1 South Prospect Street UHC, Burlington, VT 05401
| | - Sarah H. Heil
- University of Vermont, Department of Psychiatry, 1 South Prospect Street UHC, Burlington, VT 05401,University of Vermont, Department of Psychology, 1 South Prospect Street UHC, Burlington, VT 05401
| | - Gary J. Badger
- University of Vermont, Department of Medical Biostatistics, 105 Carrigan Drive, Burlington, VT 05401
| | - Jerilyn S. Metayer
- Fletcher Allen Health Care, Department of Pediatrics, 111 Colchester Avenue, Smith 551, Burlington, VT 05401
| | - Anne M. Johnston
- Fletcher Allen Health Care, Department of Pediatrics, 111 Colchester Avenue, Smith 551, Burlington, VT 05401
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