Neonatal Abstinence Syndrome

Neonatal Abstinence Syndrome/Neonatal Opioid Withdrawal Syndrome: An Ecological View of Non-Pharmacologic Interventions for Feeding Success

The number of infants diagnosed with neonatal abstinence syndrome (NAS) or neonatal opioid withdrawal syndrome (NOWS) has increased. The expression of NAS/NOWS symptoms differs and typically begins within the first few days of life, considered a critical period for feeding skill establishment, nourishment, and attachment. Non-pharmacologic interventions may be deployed to reduce or eliminate the need for replacement opioids while targeting outcomes like feeding dysfunction. Critical care providers can benefit from a structured examination of disordered feeding experiences to inform their selection of non-pharmacologic interventions. This structure can be provided using the Ecology of Human Performance model.

"Instead of just taking my baby, they could've actually given me a chance": Experiences with plans of safe care among birth parents impacted by perinatal substance use

BACKGROUND

Federal legislation mandates healthcare providers to notify child protective service (CPS) agencies and offer a voluntary care plan called a "plan of safe care" (POSC) for all infants born affected by prenatal substance use. While POSCs aim to provide supportive services for families impacted by substance use, little is known about birth parents' perceptions and experiences.

OBJECTIVE

To examine birth parents' perceptions and experiences regarding POSC.

PARTICIPANTS AND SETTING

Parents offered a POSC in Philadelphia in the prior year were included.

METHODS

This is a qualitative interview study. Participants were recruited from birth hospitals and community-based programs with telephone consent and interview procedures. Transcripts were analyzed using an inductive, grounded theory approach to identify content themes.

RESULTS

Twelve birth parents were interviewed (30.7 % of eligible, contacted individuals). Fear of CPS involvement and stigma were common. Some birth parents reported that the increased scrutiny related to POSCs negatively impacted their attitudes toward healthcare providers and medications for opioid use disorder (MOUD). While parents found the consolidated resource information helpful, many did not know how to access services. Finally, parents desired more individualized plans tailored to their unique family needs.

CONCLUSIONS

Stigma, confusion, and fear of CPS involvement undermine the goal of POSCs to support substance-exposed infants and birth parents. Providers serving this population should be transparent regarding CPS notifications, provide compassionate, non-stigmatizing care, and offer coordination services to support engagement after discharge. Policymakers should consider separating POSCs from CPS to avoid exacerbating fear and mistrust.

Prenatal opioid exposure by likelihood of exposure and risk to prenatal development: Medicaid-covered births in Wisconsin, 2010-2019

Prenatal opioid exposure is an established public health problem, in particular among Medicaid-covered births. Yet, existing prevalence rates are plausibly underestimated. We leverage extensive linked longitudinal administrative data for all Medicaid-covered live births in Wisconsin from 2010 to 2019 to estimate a range of prevalence rates using an innovative strategy that jointly accounts for both likelihood of exposure and potential risk to prenatal development. We find that 20.8% of infants may have been prenatally exposed to opioids, with 1.7% diagnosed with neonatal abstinence syndrome and an additional 1.2% having a high combined likelihood of exposure and potential risk to prenatal development, 2.6% a moderate combined likelihood and risk, and 15.3% a low or uncertain combined likelihood and risk. We assess improvements in prevalence estimates based on our nuanced classification relative to those of prior studies. Our strategy could be broadly used to quantify the scope of the opioid crisis for pregnant populations, target interventions, and promote child health and development.

Considerations and Determinants of Discharge Decisions among Prenatal Substance Exposed Infants

Limited research has examined a comprehensive set of predictors when evaluating discharge placement decisions for infants exposed to substances prenatally. Using a previously validated medical record data extraction tool, the current study examined prenatal substance exposure, infant intervention (i.e., pharmacologic, or non-pharmacologic), and demographic factors (e.g., race and ethnicity and rurality) as predictors of associations with discharge placement in a sample from a resource-poor state (N = 136; 69.9% Non-Hispanic White). Latent class analysis (LCA) was used to examine whether different classes emerged and how classes were differentially related to discharge placement decisions. Logistic regressions were used to determine whether each predictor was uniquely associated with placement decisions. Results of the LCA yielded a two-class solution comprised of (1) a Low Withdrawal Risk class, characterized by prenatal exposure to substances with low risk for neonatal abstinence syndrome (NAS) and non-pharmacologic intervention, and (2) a High Withdrawal Risk class, characterized by a high risk of NAS and pharmacologic intervention. Classes were not related to discharge placement decisions. Logistic regressions demonstrated that meth/amphetamine use during pregnancy was associated with greater odds of out of home placement above other substance types. Future research should replicate and continue examining the clinical utility of these classes.

Influence of Eat, Sleep, and Console on Infants Pharmacologically Treated for Opioid Withdrawal: A Post Hoc Subgroup Analysis of the ESC-NOW Randomized Clinical Trial

Importance

The function-based eat, sleep, console (ESC) care approach substantially reduces the proportion of infants who receive pharmacologic treatment for neonatal opioid withdrawal syndrome (NOWS). This reduction has led to concerns for increased postnatal opioid exposure in infants who receive pharmacologic treatment. However, the effect of the ESC care approach on hospital outcomes for infants pharmacologically treated for NOWS is currently unknown.

Objective

To evaluate differences in opioid exposure and total length of hospital stay (LOS) for pharmacologically treated infants managed with the ESC care approach vs usual care with the Finnegan tool.

Design, Setting, and Participants

This post hoc subgroup analysis involved infants pharmacologically treated in ESC-NOW, a stepped-wedge cluster randomized clinical trial conducted at 26 US hospitals. Hospitals maintained pretrial practices for pharmacologic treatment, including opioid type, scheduled opioid dosing, and use of adjuvant medications. Infants were born at 36 weeks' gestation or later, had evidence of antenatal opioid exposure, and received opioid treatment for NOWS between September 2020 and March 2022. Data were analyzed from November 2022 to January 2024.

Exposure

Opioid treatment for NOWS and the ESC care approach.

Main Outcomes and Measures

For each outcome (total opioid exposure, peak opioid dose, time from birth to initiation of first opioid dose, length of opioid treatment, and LOS), we used generalized linear mixed models to adjust for the stepped-wedge design and maternal and infant characteristics.

Results

In the ESC-NOW trial, 463 of 1305 infants were pharmacologically treated (143/603 [23.7%] in the ESC care approach group and 320/702 [45.6%] in the usual care group). Mean total opioid exposure was lower in the ESC care approach group with an absolute difference of 4.1 morphine milligram equivalents per kilogram (MME/kg) (95% CI, 1.3-7.0) when compared with usual care (4.8 MME/kg vs 8.9 MME/kg, respectively; P = .001). Mean time from birth to initiation of pharmacologic treatment was 22.4 hours (95% CI, 7.1-37.7) longer with the ESC care approach vs usual care (75.4 vs 53.0 hours, respectively; P = .002). No significant difference in mean peak opioid dose was observed between groups (ESC care approach, 0.147 MME/kg, vs usual care, 0.126 MME/kg). The mean length of treatment was 6.3 days shorter (95% CI, 3.0-9.6) in the ESC care approach group vs usual care group (11.8 vs 18.1 days, respectively; P < .001), and mean LOS was 6.2 days shorter (95% CI, 3.0-9.4) with the ESC care approach than with usual care (16.7 vs 22.9 days, respectively; P < .001).

Conclusion and Relevance

When compared with usual care, the ESC care approach was associated with less opioid exposure and shorter LOS for infants pharmacologically treated for NOWS. The ESC care approach was not associated with a higher peak opioid dose, although pharmacologic treatment was typically initiated later.

Trial Registration

ClinicalTrials.gov Identifier: NCT04057820.

Society for Maternal-Fetal Medicine Consult Series #68: Sickle cell disease in pregnancy

Pregnant individuals with sickle cell disease have an increased risk of maternal and perinatal morbidity and mortality. However, prepregnancy counseling and multidisciplinary care can lead to favorable maternal and neonatal outcomes. In this consult series, we summarize what is known about sickle cell disease and provide guidance for sickle cell disease management during pregnancy. The following are Society for Maternal-Fetal Medicine recommendations.

Transplacental methadone exposure and risk of Neonatal Opioid Withdrawal Syndrome

STUDY OBJECTIVE

Neonatal opioid withdrawal syndrome (NOWS) is a condition that often occurs in neonates born to mothers who received methadone treatment for opioid use disorder during pregnancy. Early identification and treatment of infants at risk of NOWS may improve clinical outcomes. The purpose of this study was to evaluate whether maternal and umbilical cord plasma concentrations of methadone and its metabolite, 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP), could predict the need for NOWS treatment.

DESIGN

Single-center prospective study.

SETTING

University of Michigan Neonatal Intensive Care Unit.

PATIENTS

The study included 11 opioid-dependent mother-infant dyads, where the mothers were treated with methadone at 34 weeks' gestation or later.

INTERVENTION

Maternal and cord blood samples were collected from the study participants.

MEASUREMENTS AND MAIN RESULTS

Maternal and cord plasma concentrations of methadone and EDDP were determined. Six out of the 11 infants required treatment for NOWS. Maternal methadone plasma concentrations were comparable between infants requiring and not requiring NOWS treatment (329.1 ± 229.7 ng/mL vs. 413.2 ± 329.8 ng/mL). However, the average cord plasma methadone concentration in infants who did not require NOWS treatment was 2.9-fold higher than in those who required the treatment (120.0 ± 88.6 ng/mL vs. 40.9 ± 24.4 ng/mL), although the difference was not statistically significant. The ratios of maternal-to-cord methadone plasma concentrations were significantly higher in patients who required treatment for NOWS compared with those who did not (7.7 ± 1.9 vs. 3.5 ± 1.6, p = 0.003). Maternal and cord plasma EDDP concentrations and the maternal-to-cord plasma EDDP concentration ratios did not differ between patients who required and did not require treatment for NOWS.

CONCLUSIONS

The results suggest that methadone permeability across the blood-placental barrier may affect in utero exposure to methadone, and the maternal-to-cord methadone plasma concentration ratio could be a potential biomarker for predicting the need for NOWS treatment.

Prenatal Substance Exposure and Neonatal Abstinence Syndrome: State Estimates from the 2016-2020 Transformed Medicaid Statistical Information System

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.

Improving Outcomes in Infants With Neonatal Abstinence Syndrome With the Eat, Sleep, Console Method

BACKGROUND

Neonatal abstinence syndrome (NAS) is a significant public health concern. A quality improvement project was executed in a neonatal intensive care unit at a large urban hospital. The aim was to address the prolonged hospitalization of infants and exposure to medications to treat NAS.

PURPOSE

The goal was to determine whether the eat, sleep, console (ESC) method decreases the length of stay (LOS) and morphine usage when compared with the Finnegan Neonatal Abstinence Scoring System (FNASS).

METHODS

The inclusion criteria were 36 weeks' or longer gestation and exposure to opiates in utero. The FNASS method was replaced by the ESC method with a refocus on nonpharmacologic care. Data were collected for 6 months during implementation of the ESC method and compared with the 6 months prior to implementation.

RESULTS

The results of the project include: the average LOS decreased from 25.9 days to 13.7 days, a 47% reduction; the rate of scheduled morphine initiation decreased from 58% to 7%, an 88% reduction; as-needed morphine initiation decreased from 33% to 7%, a 79% reduction; and the rate of adjunctive medication initiation decreased from 17% to 0%, a 100% reduction.

IMPLICATIONS FOR PRACTICE AND RESEARCH

The outcomes of LOS and rate of morphine usage were significantly improved when using the ESC method when compared with the FNASS at this facility. The results support future implications including expanding the ESC program to the well newborn population at this facility and other similar units. Further research needs to be done on long-term neurodevelopmental outcomes.

Reconsidering the use of urine drug testing in reproductive settings

The urine drug test is ubiquitous within reproductive healthcare settings. Although the test can have evidence-based use for a patient and clinician, in practice, it is often applied in ways that are driven by bias and stigma, do not correctly inform decisions about clinical aspects of patient care, and cause devastating ripple effects through social and legal systems. This paper proposes a framework of guiding questions to prompt reflection on (1) the question the clinical team is trying to answer, (2) whether a urine drug test answers the question at hand, (3) how testing benefits compare with the associated risks, (4) a more effective tool for clinical decision-making if the urine drug test does not meet the standards for use, and (5) individual and institutional biases affecting decision-making. We demonstrate the use of this framework using 3 common uses of the urine drug test within abortion care and labor and delivery settings.

Procedural pain assessment in neonates at risk of neonatal opioid withdrawal syndrome: a scoping review protocol

OBJECTIVE

The objective of this review is to identify evidence on pain assessment during acute procedures in hospitalized neonates at risk of neonatal opioid withdrawal syndrome (NOWS).

INTRODUCTION

While all neonates are routinely exposed to various painful procedures, neonates at risk of NOWS have longer hospital stays and are exposed to multiple painful procedures. NOWS occurs when a neonate is born to a birth parent who identifies as having sustained opioid use (such as morphine or methadone) during pregnancy. Accurate pain assessment and management during painful procedures is critical for minimizing the well-documented adverse effects of unmanaged pain in neonates. While pain indicators and composite pain scores are valid and reliable for healthy neonates, there is no review of evidence regarding procedural pain assessment in neonates at risk of NOWS.

INCLUSION CRITERIA

Eligible studies will include those reporting on hospitalized pre-term and full-term neonates at risk of NOWS having pain assessments (ie, behavioral indicators, physiological indicators, validated composite pain scores) during and/or after exposure to an acute painful procedure.

METHODS

This review will follow the JBI scoping review methodology. Databases to be searched will include MEDLINE (Ovid), CINAHL (EBSCO), Embase, PsyclNFO (EBSCO), and Scopus. The relevant data will be extracted by 2 reviewers using a modified JBI extraction tool. The results will be summarized in narrative and tabular format, including the components of participants, concept, and context (PCC).

REVIEW REGISTRATION

Open Science Framework https://osf.io/fka8s .

Actigraphy: An Adjunctive Method to Measure Irritability in Opioid-Exposed Newborns

Background and purpose: Conventional measures of withdrawal in newborns with prenatal opioid exposure (POE) rely on nursing assessments, including the subjective judgment of infant irritability. This study investigated limb movement actigraphy as a tool for providing an objective, quantifiable measure of underlying distress. Methods: Correlational analyses compared continuous physiological-detected movement actigraphy and clinical intervallic-scored symptomology (modified Finnegan system) obtained from a control cohort of 37 term neonates with POE studied in their crib in the newborn unit (1-8 days). Results: Infants spent 15% crib time in high movement activity (>100 movements/minute; index irritability) and 38% crib time in low activity (0-5 movements/minute; index calm). There was a significant positive association between actigraphy and Finnegan composite score (r = .28, P = .001) and between actigraphy and subcomponent scores (i.e., central nervous system, gastrointestinal, and metabolic-vasomotor-respiratory). Conclusion: Movement activity via actigraphy captures underlying distress and calm not measured by conventional assessments. Such objective, quantifiable measures can serve to promote equitable assessment and treatment of hospitalized newborns with POE.

Reducing daily dosing in opioid prescriptions in 11 safety net emergency departments

BACKGROUND

The United States continues to face a significant issue with opioid misuse, overprescribing, dependency, and overdose. Electronic health record (EHR) interventions have shown to be an effective tool to modify opioid prescribing behaviors. This quality improvement project describes an EHR intervention to reduce daily dosing in opioid prescriptions in 11 emergency departments (ED) across the largest safety net health system in the US.

MEASURES

The primary outcome measure was the rates of oxycodone-acetaminophen 5-325 mg prescriptions exceeding 50 morphine milligram equivalents per day (MMED) pre- vs. post-intervention; and stratified by individual hospitals and provider type.

INTERVENTION

The defaults for dose and frequency were uniformly changed to 'every 6 hours as needed' and '1 tablet', respectively, across 11 EDs.

OUTCOMES

The percentage of prescriptions greater than or equal to 50 MMED decreased from 46.0% (1624 of 3530 prescriptions) to 1.6% (52 of 3165 prescriptions) (96.4% relative reduction; p < 0.001). All 11 hospitals had a significant reduction in prescriptions exceeding 50 MMED. Nurse practitioners had the highest relative reduction of prescriptions exceeding 50 MMED at 100% (p < 0.001), and the attendings/fellows had the lowest relative reduction at 95.6% (p < 0.001).

CONCLUSIONS/LESSONS LEARNED

Default nudges are a simple yet powerful intervention that can strongly influence opioid prescribing patterns.

Substance Use and the Nervous System

OBJECTIVE

This article informs and updates the practicing neurologist on the current landscape of known neurologic injuries linked to the use of illicit drugs, focusing on emerging agents.

LATEST DEVELOPMENTS

Synthetic opioids such as fentanyl and similar derivatives have exploded in prevalence, becoming the leading cause of overdose fatalities. The higher potency of synthetic opioids compared with semisynthetic and nonsynthetic opiates poses an increased risk for unintentional overdose when found as an adulterant in other illicit drug supplies such as heroin. Conversely, misinformation about the risk of symptomatic exposure to fentanyl through casual contact with the skin and ambient air has led to misdirected fear and stigma that threatens to impede valid harm-reduction measures for fentanyl users at risk of actual overdose. Finally, during the COVID-19 pandemic, overdose rates and deaths continued to climb, especially among those who use opioids and methamphetamine.

ESSENTIAL POINTS

A variety of potential neurologic effects and injuries can occur with illicit drug use owing to the diverse properties and mechanisms of action of the various classes. Many high-risk agents are not detected on standard drug screens, including so-called designer drugs, and the practicing neurologist is best served by recognizing the clinical features of the traditional toxidrome and other potential idiosyncratic effects of various illicit agents.

Postpartum Contraceptive Use, Pregnancy Intentions in Women With and Without a Delivery of a NAS-Affected Infant in Delaware, 2012-2018

Objective

Assess differences in postpartum contraceptive use and pregnancy intentions in women with a recent live birth who delivered a neonatal abstinence syndrome (NAS) affected infant.

Study Design

Using linked Delaware Birth Certificate Data, Hospital Discharge Data and PRAMS data for 2012-2018 (n = 6,358 singleton births), we assessed differences among women with and without a delivery of an NAS-affected infant by effective postpartum contraceptive use and pregnancy intentions. We calculated prevalence estimates, crude (cPOR), and prevalence odds ratios adjusted (aPOR) for NAS by maternal characteristics. We used alpha ≤ 0.05 to determine statistical significance.

Results

Prevalence of NAS was 2.2% (95% CI: 1.8 - 2.6). Effective postpartum contraceptive use was 60.4% (95% CI: 51.9-69.0) among women with delivery of an NAS-affected infant compared with a non-NAS delivery 56.4% (95% CI: 55.1-57.8%) and cPOR was 1.2 (95% CI: 0.8-1.7). Prevalence of intended pregnancy was 26.5% (95% CI: 18.9-34.0) among women with delivery of an NAS-affected infant compared with a non-NAS delivery 53.0% (95% CI: 51.7-54.4) and cPOR was 0.3 (95% CI: 0.2-0.5). After adjustment, women who delivered an NAS-affected infant had lower odds (aPOR = 0.5; 95% CI: 0.3-0.8) of indicating that their pregnancy was intended as compared to those who did not deliver an NAS-affected infant.

Conclusions

Our study found no association between delivery of an NAS-affected infant and use of an effective postpartum contraceptive method. However, we found that pregnancy intendedness was lower among women delivering an NAS-affected infant compared with women without an NAS delivery even after accounting for maternal characteristics.

Parental Caregivers' Ability to Leave the Postpartum Unit During the COVID-19 Pandemic and Effects on Neonatal Abstinence Syndrome

OBJECTIVE

To determine if a policy change that limited the ability of parental caregivers to leave the postpartum unit during the COVID-19 pandemic influenced neonatal abstinence syndrome (NAS) scores, admissions to the NICU for NAS treatment, and length of stay (LOS) on the nursing unit.

DESIGN

Retrospective chart review.

SETTING

/Local Problem: During the pandemic, a change in policy limited parental caregivers from leaving the nursing unit.

PARTICIPANTS

Neonates being screened for NAS during the period before the policy change from April 2, 2019, through April 1, 2020 (n = 44), and the period after the policy change (n = 23) from April 2, 2020, to April 1, 2021.

MEASUREMENTS

Levene's test was used to determine homogeneity of variance before independent t tests on mean NAS scores and LOS across groups. A linear mixed-effects model tested differences in NAS scores, accounting for time and group. Chi-square tests determined differences in the number of neonates transferred to the NICU across groups.

RESULTS

No differences between group variables were found, with the exception of feeding type and cocaine/cannabinoid use (p < .05). No significant differences were found in mean NAS scores (p = .96), LOS (p = .77) or NAS scores accounting for time and between groups (p = .069). Transfers to the NICU in the pre-policy change group were significantly greater (p = .05).

CONCLUSION

Although no decrease was observed for mean NAS scores and LOS of the neonates, a decrease in transfers to the NICU for pharmacologic treatment for NAS was observed. Further research is required to determine casual relationships for the decrease in NICU transfers.

Early Identification of Atypical Motor Performance of Infants With Prenatal Opioid Exposure

PURPOSE

To investigate the association between prenatal opioid exposure (POE) and newborn infants' motor performance to aid in the early identification of developmental delays.

METHODS

Nineteen infants with POE requiring pharmacological treatment, 27 infants with POE without pharmacological treatment, and 25 infants without POE were assessed via the Test of Infant Motor Performance (TIMP).

RESULTS

Infants in both groups with POE had lower TIMP scores than infants without POE. There was no difference between the TIMP scores of infants with POE who required pharmacological treatment and infants with POE who did not require pharmacological treatment.

CONCLUSIONS

The TIMP can detect differences in motor performance of infants with POE. Regardless of whether infants required pharmacological treatment, POE was associated with lower motor performance. Those working in hospital or early intervention settings can use the TIMP to identify early delays in infants with POE and refer for intervention.

Polygenic risk scores and the need for pharmacotherapy in neonatal abstinence syndrome

BACKGROUND

The aim of this study was to identify genetic variants associated with NAS through a genome-wide association study (GWAS) and estimate a Polygenic Risk Score (PRS) model for NAS.

METHODS

A prospective case-control study included 476 in utero opioid-exposed term neonates. A GWAS of 1000 genomes-imputed genotypes was performed to identify variants associated with need for pharmacotherapy for NAS. PRS models for estimating genetic predisposition were generated via a nested cross-validation approach using 382 neonates of European ancestry. PRS predictive ability, discrimination, and calibration were assessed.

RESULTS

Cross-ancestry GWAS identified one intergenic locus on chromosome 7 downstream of SNX13 exhibiting genome-wide association with need for pharmacotherapy. PRS models derived from the GWAS for a subset of the European ancestry neonates reliably discriminated between need for pharmacotherapy using cis variant effect sizes within validation sets of European and African American ancestry neonates. PRS were less effective when applying variant effect sizes across datasets and in calibration analyses.

CONCLUSIONS

GWAS has the potential to identify genetic loci associated with need for pharmacotherapy for NAS and enable development of clinically predictive PRS models. Larger GWAS with additional ancestries are needed to confirm the observed SNX13 association and the accuracy of PRS in NAS risk prediction models.

IMPACT

Genetic associations appear to be important in neonatal abstinence syndrome. This is the first genome-wide association in neonates with neonatal abstinence syndrome. Polygenic risk scores can be developed examining single-nucleotide polymorphisms across the entire genome. Polygenic risk scores were higher in neonates receiving pharmacotherapy for treatment of their neonatal abstinence syndrome. Future studies with larger cohorts are needed to better delineate these genetic associations.

Adverse Maternal Experiences and Neonatal Abstinence Syndrome

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.

Drug testing in support of the diagnosis of neonatal abstinence syndrome: The current situation

Illicit drug use during pregnancy is a concern worldwide, with many international studies describing attempted strategies to mitigate this problem. Drug misuse during pregnancy is associated with significant maternal as well as perinatal complications, which include a high incidence of stillbirths, fetal distress, neonatal abstinence syndrome (NAS) and increased neonatal mortality. Unfortunately, the identification of a drug-exposed mother or neonate is challenging. Maternal disclosure of drug use is often inaccurate, principally due to psychosocial factors including behavioral denial or the fear of the consequences resulting from such admissions. Likewise, many infants who have been exposed to drugs in utero may appear normal at birth and initially show no overt manifestations of drug effects. Thus, the identification of the drug-exposed infant requires a high index of clinical suspicion. Conversely, analytical testing is an objective means of determining drug exposure when it may be necessary to document proof of the infant's exposure to illicit drugs. The review will discuss the different matrices that are most commonly used for testing (e.g., maternal urine, neonatal urine, meconium, and umbilical cord), the strengths and limitations for each matrix, which drugs and metabolites are appropriate for testing, the various testing methods, and the advantages and disadvantages of each method.

Pediatric Primary Care Diagnoses Among Children with Intrauterine Opioid Exposure

BACKGROUND AND OBJECTIVES

Characterizing common concerns for children with intrauterine opioid exposure (IOE) can inform tailored primary care.

METHODS

Retrospective analysis of primary care data of children with IOE from birth to age two years within one multi-state pediatric health system. Well child care (WCC) and problem-based visit diagnoses were categorized, and descriptive statistics were tabulated.

RESULTS

Three hundred and eighty-five (385) children with IOE had 3,622 primary care visits, of which 51.4% were WCC and 48.6% were problem-based. Most frequent visit diagnoses were upper respiratory complaints (14.8% of visits), feeding difficulties (12.2%), and perinatal viral exposure (9.8%). Although visit type (WCC vs. problem-based) varied across diagnostic category, frequent utilization of both visit types were documented for several diagnoses in infancy (e.g., fussiness/colic, feeding difficulties).

CONCLUSIONS

Well child care visits for children with IOE are key opportunities for anticipatory guidance with an emphasis on problems that may contribute to acute health care utilization, particularly in early infancy.

The Eat, Sleep, Console Method: A Literature Review

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.

Morphine versus methadone for neonatal opioid withdrawal syndrome: a randomized controlled pilot study

BACKGROUND

Neonatal Opioid Withdrawal Syndrome (NOWS) is a significant public health issue and while millions of neonates are affected each year, an optimal pharmacologic weaning protocol has yet to be demonstrated. In this study, we compare hospital length of stay (LOS) and length of treatment (LOT) for treatment of neonatal opioid withdrawal (NOWS) with morphine versus methadone.

METHODS

This was a single-site, open-label, randomized controlled pilot study conducted from October 2016-September 2018. Infants were eligible if their primary in-utero drug exposure was heroin, oral opioids, or methadone and they were born at greater than or equal to 34 weeks gestation. Infants were excluded for serious medical comorbidities and primary in-utero exposure to buprenorphine.

RESULTS

Sixty-one infants were enrolled; 30 were randomized to methadone treatment, and 31 to morphine treatment. Overall 46% of infants required treatment for NOWS. LOS and LOT for infants treated with morphine was 17.9 days and 14.7 days respectively, compared to 16.1 days and 12.8 days for babies treated with methadone (p = 0.5, p = 0.54). Infants treated with morphine received lower total morphine equivalents than those treated with methadone (9.7 vs. 33, p < 0.01). Three treated infants in the methadone group required transfer to the Neonatal Intensive Care Unit, versus no infants in the morphine group.

CONCLUSIONS

Infants treated with morphine versus methadone had no significant differences in LOS or LOT in this pilot study. Infants treated with methadone received up to 3 times the opioid based on morphine equivalents as infants treated with morphine and had more transfers to the NICU for over sedation.

CLINICAL TRIAL REGISTRATION

Morphine Versus Methadone for Opiate Exposed Infants With Neonatal Abstinence Syndrome NCT02851303 , initiated 01/08/2016.

Prenatal opioid-exposed infant extracellular miRNA signature obtained at birth predicts severity of neonatal opioid withdrawal syndrome

Prenatal opioid exposure (POE) is commonly associated with neonatal opioid withdrawal syndrome (NOWS), which is characterized by a broad variability in symptoms and severity. Currently there are no diagnostic tools to reliably predict which infants will develop severe NOWS, while risk stratification would allow for proactive decisions about appropriate clinical monitoring and interventions. The aim of this prospective cohort study was to assess if extracellular microRNAs (miRNAs) in umbilical cord plasma of infants with POE could predict NOWS severity. Participants (n = 58) consisted of pregnant women receiving medications for opioid use disorder and their infants. NOWS severity was operationalized as the need for pharmacologic treatment and prolonged hospitalization (≥ 14 days). Cord blood miRNAs were assessed using semi-quantitative qRT-PCR arrays. Receiver operating characteristic curves and area under the curve (AUC) were estimated. The expression of three miRNAs (miR-128-3p, miR-30c-5p, miR-421) predicted need for pharmacologic treatment (AUC: 0.85) and prolonged hospitalization (AUC: 0.90). Predictive validity improved after two miRNAs (let-7d-5p, miR-584-5p) were added to the need for pharmacologic treatment model (AUC: 0.94) and another two miRNAs (let-7b-5p, miR-10-5p) to the prolonged hospitalization model (AUC: 0.99). Infant cord blood extracellular miRNAs can proactively identify opioid-exposed neonates at high-risk for developing severe NOWS.

Severity of neonatal opioid withdrawal syndrome with prenatal exposure to serotonin reuptake inhibitors

OBJECTIVE

To evaluate the severity of neonatal opioid withdrawal syndrome (NOWS) in infants prenatally exposed to medications for opioid use disorder (MOUD) and serotonin reuptake inhibitors (SRI).

METHODS

A prospective cohort included 148 maternal-infant pairs categorized into MOUD (n = 127) and MOUD + SRI (n = 27) groups. NOWS severity was operationalized as the infant's need for pharmacologic treatment with opioids, duration of hospitalization, and duration of treatment. The association between prenatal SRI exposure and the need for pharmacologic treatment (logistic regression), time-to-discharge, and time-to-treatment discontinuation (Cox proportional hazards modeling) was examined after adjusting for the type of maternal MOUD, use of hydroxyzine, other opioids, benzodiazepines/sedatives, alcohol, tobacco, marijuana, gestational age, and breastfeeding.

RESULTS

Infants in the MOUD + SRI group were more likely to receive pharmacologic treatment for NOWS (OR = 3.58; 95% CI: 1.31; 9.76) and had a longer hospitalization (median: 11 vs. 6 days; HR = 0.54; 95% CI: 0.33; 0.89) compared to the MOUD group. With respect to time-to-treatment discontinuation, no association was observed in infants who received treatment (HR = 0.59; 95% CI: 0.26, 1.32); however, significant differences were observed in the entire sample (HR = 0.55; 95% CI: 0.34, 0.89).

CONCLUSIONS

Use of SRIs among pregnant women on MOUD might be associated with more severe NOWS.

IMPACT

A potential drug-drug interaction between maternal SRIs and opioid medications that inhibit the reuptake of serotonin has been hypothesized but not carefully evaluated in clinical studies. Results of this prospective cohort indicate that the use of SRIs among pregnant women on MOUD is associated with more severe neonatal opioid withdrawal syndrome. This is the first prospective study which carefully examined effect modification between the type of maternal MOUD and SRI use on neonatal outcomes. This report lays the foundation for treatment optimization in pregnant women with co-occurring mental health and substance use disorders.

Behavioral and Gene Regulatory Responses to Developmental Drug Exposures in Zebrafish

Developmental consequences of prenatal drug exposure have been reported in many human cohorts and animal studies. The long-lasting impact on the offspring-including motor and cognitive impairments, cranial and cardiac anomalies and increased prevalence of ADHD-is a socioeconomic burden worldwide. Identifying the molecular changes leading to developmental consequences could help ameliorate the deficits and limit the impact. In this study, we have used zebrafish, a well-established behavioral and genetic model with conserved drug response and reward pathways, to identify changes in behavior and cellular pathways in response to developmental exposure to amphetamine, nicotine or oxycodone. In the presence of the drug, exposed animals showed altered behavior, consistent with effects seen in mammalian systems, including impaired locomotion and altered habituation to acoustic startle. Differences in responses seen following acute and chronic exposure suggest adaptation to the presence of the drug. Transcriptomic analysis of exposed larvae revealed differential expression of numerous genes and alterations in many pathways, including those related to cell death, immunity and circadian rhythm regulation. Differential expression of circadian rhythm genes did not correlate with behavioral changes in the larvae, however, two of the circadian genes, arntl2 and per2, were also differentially expressed at later stages of development, suggesting a long-lasting impact of developmental exposures on circadian gene expression. The immediate-early genes, egr1, egr4, fosab, and junbb, which are associated with synaptic plasticity, were downregulated by all three drugs and in situ hybridization showed that the expression for all four genes was reduced across all neuroanatomical regions, including brain regions implicated in reward processing, addiction and other psychiatric conditions. We anticipate that these early changes in gene expression in response to drug exposure are likely to contribute to the consequences of prenatal exposure and their discovery might pave the way to therapeutic intervention to ameliorate the long-lasting deficits.

Whole body massage for newborns: A report on non-invasive methodology for neonatal opioid withdrawal syndrome

BACKGROUND

Infants with in-utero exposure to opioids are at risk Neonatal Opioid Withdrawal Syndrome (NOWS) and non-pharmacological methods of care, like swaddling, quiet ambient environment are routinely recommended but are not systematically studied. We hypothesized that opioid exposed infants can tolerate whole body massage while hospitalized.

METHODS

This is a prospective observational study (August 2017 to January 2019) and infants of mothers having a history of opioids use (OUD) were included. Infants received whole body massage for 30 minutes from birth till discharge home. Infants heart rate (HR), respiratory rate (RR), systolic (sBP) and diastolic blood pressure (dBP) were recorded prior to and at the end of massage session.

RESULTS

The pilot study enrolled 30 infants. The mean birth weight and gestational age were 38±1 weeks and 2868±523 grams, respectively. All massage sessions were well tolerated. There was marked decrease in HR, systolic and diastolic BP and RR, (p < 0.01) in all study infants post massage, more profound among infants with NOWS (p < 0.01) than without NOWS.

CONCLUSIONS

Whole body massage is very well tolerated by infants with in-utero opioid exposure. Infants with NOWS had marked decrease in their HR and BP from their baseline after massage.

Opioids and the developing brain: time to rethink perinatal care for infants of opioid-dependent mothers

Illicit use of opioids is a global health crisis with major implications for women and children. Strategies for managing opioid use disorder (OUD) in pregnancy have been tested over the past 40 years, but studies have focused on maternal and pregnancy outcomes, with less attention given to long-term follow-up of exposed children. Here, we provide a narrative review of recent advances in the assessment and management of neonatal opioid withdrawal syndrome (NOWS), and we summarise evidence from multiple domains-neuroimaging, electrophysiology, visual development and function, neurodevelopment, behaviour, cognition and education-which suggests that prenatal opioid exposure modifies child development. Further studies are required to determine the optimal management of pregnant women with OUD and babies with NOWS. We identify knowledge gaps and suggest that future study designs should evaluate childhood outcomes, including infant brain development and long-term neurocognitive and visual function.

Incidence of Neonatal Abstinence Syndrome (NAS) in Castilla y Leon (Spain)

Introduction: Neonatal Abstinence Syndrome (NAS) is considered a Public Health problem that is defined as a group of symptoms that appear in the newborn due to withdrawal from intrauterine drug exposure. Objective: The aim of this study was to analyze the incidence of NAS in Castilla y León from 2000 to 2019. Methodology: Data of NAS cases in Castilla y León from 2000 to 2019 were obtained. NAS incidence per 1000 births was calculated and the correlation among data from different provinces and years was analyzed. Results: The cumulative incidence of NAS in Castilla y León per 1000 births between 2000-2019 was 0.91‰, with great interprovincial variability. The provinces of Zamora and Palencia stand out, with high incidence rates of NAS despite their low birth rates. The temporal trend points towards a decrease in incidence from 2000 to 2019. Opioids such as methadone, cannabis, benzodiazepines and poly-drug use are the most prevalent drugs causing NAS, and it has also been observed that methadone is being replaced by cannabis as the major cause of NAS cases at the University Hospital in Salamanca in recent years. Conclusions: The incidence of NAS in Castilla y León decreased in 2004 and remained constant until 2019, but it shows great interprovincial variability. It is necessary to implement a national NAS Registry to obtain comprehensive information regarding its incidence.

A Meta-Analysis of Breastfeeding Effects for Infants With Neonatal Abstinence Syndrome

Supplemental digital content is available in the text.

Background

Neonatal abstinence syndrome (NAS) rates have dramatically increased. Breastfeeding is a nonpharmacological intervention that may be beneficial, reducing NAS symptom severity and thus the need for and duration of pharmacological treatment and length of hospital stay.

Objectives

Conduct meta-analysis to determine whether breastfeeding results in better outcomes for NAS infants. Variables included symptom severity, need for and duration of pharmacological treatment, and length of hospital stay.

Methods

PubMed, Scopus, Embase, and Cochrane Library were searched from 2000 to 2020, and comparative studies examining breastfeeding for NAS infants were extracted. Randomized trials and cohort studies were included. Data were extracted and evaluated with Review Manager Version 5.3. A random-effects model was used to pool discontinuous outcomes using risk ratio and 95% confidence intervals. Continuous outcomes were evaluated by mean differences and 95% confidence intervals.

Results

Across 11 studies, 6,375 neonates were included in the meta-analysis. Using a random-effects analysis, breastfeeding reduced initiation of pharmacological treatment, reduced duration of pharmacological treatment, and reduced length of stay. No differences were detected for severity of NAS symptoms. Most studies only reported one to two variables of interest. For most studies, these variables were not the primary study outcomes. All studies were found to be of low risk and good quality based on the Cochrane Risk Assessment Tools. Varying breastfeeding definitions limit generalizability.

Discussion

Breastfeeding is associated with decreased initiation and duration of pharmacological treatment and length of stay.

Sex Differences in Behavioral and Brainstem Transcriptomic Neuroadaptations following Neonatal Opioid Exposure in Outbred Mice

The opioid epidemic led to an increase in the number of neonatal opioid withdrawal syndrome (NOWS) cases in infants born to opioid-dependent mothers. Hallmark features of NOWS include weight loss, severe irritability, respiratory problems, and sleep fragmentation. Mouse models provide an opportunity to identify brain mechanisms that contribute to NOWS. Neonatal outbred Swiss Webster Cartworth Farms White (CFW) mice were administered morphine (15 mg/kg, s.c.) twice daily from postnatal day 1 (P1) to P14, an approximation of the third trimester of human gestation. Female and male mice underwent behavioral testing on P7 and P14 to determine the impact of opioid exposure on anxiety and pain sensitivity. Ultrasonic vocalizations (USVs) and daily body weights were also recorded. Brainstems containing pons and medulla were collected during morphine withdrawal on P14 for RNA sequencing. Morphine induced weight loss from P2 to P14, which persisted during adolescence (P21) and adulthood (P50). USVs markedly increased at P7 in females, emerging earlier than males. On P7 and P14, both morphine-exposed female and male mice displayed hyperalgesia on the hot plate and tail-flick assays, with females showing greater hyperalgesia than males. Morphine-exposed mice exhibited increased anxiety-like behavior in the open-field arena on P21. Transcriptome analysis of the brainstem, an area implicated in opioid withdrawal and NOWS, identified pathways enriched for noradrenergic signaling in females and males. We also found sex-specific pathways related to mitochondrial function and neurodevelopment in females and circadian entrainment in males. Sex-specific transcriptomic neuroadaptations implicate unique neurobiological mechanisms underlying NOWS-like behaviors.

Improving the Assessment of Neonatal Abstinence Syndrome (NAS)

Neonatal Abstinence Syndrome (NAS) is a public health problem of epidemic proportions. The Finnegan Neonatal Abstinence Scoring System (FNASS) is the tool most widely used to evaluate NAS. However, it is limited by its lack of interrater reliability and standardized approach. Surveys to evaluate the FNASS were distributed to nurses at the Women and Infants Hospital in Providence, RI, USA. Infants (n = 78) treated for NAS and born to methadone-maintained mothers were examined to compare items administered from the FNASS and the NICU Network Neurobehavioral Scale (NNNS). All nurses reported that the FNASS was somewhat to very subjective. More than half reported that it was somewhat to not accurate and a new scoring method is needed to accurately diagnose NAS. Correlations between FNASS items and NNNS items showed 9 of 32 (28.1%) correlations were strong (rs > 0.5), 5 of 32 (15.6%) were moderate (0.3 < rs < 0.5), and 10 of 32 (31.3%) were weak (0.1 < rs < 0.3). Principal component factor analysis (PCA) of the NNNS explained more variance (35.1%) than PCA of NNNS and FNASS items combined (33.1%). The nursing survey supported the need for developing a more objective exam to assess NAS. NNNS exam items may be used to improve the evaluation of NAS.

The Term Newborn: Prenatal Substance Exposure

Care for pregnant patients with substance use disorder must be provided in a nonjudgmental manner with recognition of addiction as a chronic medical illness in order to establish a therapeutic relationship and improve outcomes. All pregnant patients should be screened for substance use during prenatal care. Screening can be accomplished through several validated screening tools. Patients who screen positive need to be evaluated and referred for treatment as appropriate. This article reviews specific adverse perinatal outcomes associated with the use of a variety of substances and provides guidance on exposure with continued breastfeeding.

Neonatal Abstinence Syndrome in Rural Appalachia

As the United States faces the repercussions of the current opioid epidemic, it is important for social workers to be able to identify risks for poor birth outcomes in infants with neonatal abstinence syndrome (NAS). Although some studies have identified single risk factors, no studies have tested associations between total amount of risk (that is, cumulative risk) and birth outcomes in infants with NAS. Authors examined 318 mothers who used opioids during pregnancy and their infants' birthweight, length, head circumference, and Apgar scores (which measure overall infant health after birth). All infants were admitted to a neonatal intensive care unit in Appalachia and were diagnosed with NAS. Authors found that high cumulative risk during pregnancy was associated with lower birthweight and Apgar scores one and five minutes after birth as well as shorter length and smaller head circumference at birth. Social workers are encouraged to assess for the quantity of prenatal adversity experienced by the mothers they serve and to consider multicomponent, comprehensive community-based interventions to reduce cumulative risk.

Infant Mortality Associated With Prenatal Opioid Exposure

IMPORTANCE

Knowledge of health outcomes among opioid-exposed infants is limited, particularly for those not diagnosed with neonatal opioid withdrawal syndrome (NOWS).

OBJECTIVES

To describe infant mortality among opioid-exposed infants and identify how mortality risk differs in opioid-exposed infants with and without a diagnosis of NOWS compared with infants without opioid exposure.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study of maternal-infant dyads was conducted, linking health care claims with vital records for births from January 1, 2010, to December 31, 2014, with follow-up of infants until age 1 year (through 2015). Maternal-infant dyads were included if the infant was born in Texas at 22 to 43 weeks' gestational age to a woman aged 15 to 44 years insured by Texas Medicaid. Data analysis was performed from May 2019 to October 2020.

EXPOSURE

The primary exposure was prenatal opioid exposure, with infants stratified by the presence or absence of a diagnosis of NOWS during the birth hospitalization.

MAIN OUTCOMES AND MEASURES

Risk of infant mortality (death at age <365 days) was examined using Kaplan-Meier and log-rank tests. A series of logistic regression models was estimated to determine associations between prenatal opioid exposure and mortality, adjusting for maternal and neonatal characteristics and clustering infants at the maternal level to account for statistical dependence owing to multiple births during the study period.

RESULTS

Among 1 129 032 maternal-infant dyads, 7207 had prenatal opioid exposure, including 4238 diagnosed with NOWS (mean [SD] birth weight, 2851 [624] g) and 2969 not diagnosed with NOWS (mean [SD] birth weight, 2971 [639] g). Infant mortality was 20 per 1000 live births for opioid-exposed infants not diagnosed with NOWS, 11 per 1000 live births for infants with NOWS, and 6 per 1000 live births in the reference group (P < .001). After adjusting for maternal and neonatal characteristics, mortality in infants with a NOWS diagnosis was not significantly different from the reference population (odds ratio, 0.82; 95% CI, 0.58-1.14). In contrast, the odds of mortality in opioid-exposed infants not diagnosed with NOWS was 72% greater than the reference population (odds ratio, 1.72; 95% CI, 1.25-2.37).

CONCLUSIONS AND RELEVANCE

In this study, opioid-exposed infants appeared to be at increased risk of mortality, and the treatments and supports provided to those diagnosed with NOWS may be protective. Interventions to support opioid-exposed maternal-infant dyads are warranted, regardless of the perceived severity of neonatal opioid withdrawal.

Post-discharge healthcare utilization in infants with neonatal opioid withdrawal syndrome

The opioid epidemic in the United States has led to a significant increase in the incidence of neonatal opioid withdrawal syndrome (NOWS); however, the understanding of long-term consequences of NOWS is limited. The objective of this study was to evaluate post-discharge healthcare utilization in infants with NOWS and examine the association between NOWS severity and healthcare utilization. A retrospective cohort design was used to ascertain healthcare utilization in the first year after birth-related discharge using the CERNER Health Facts® database. ICD-9/ICD-10 diagnostic codes were used to identify live births and to classify infants into two study groups: NOWS and uncomplicated births (a 25% random sample). Evaluated outcomes included rehospitalization, emergency department (ED) visits within 30-days and one-year after discharge, and a composite one-year utilization event (either hospitalization or emergency department visit during that year). NOWS severity was operationalized as pharmacologic treatment, length of hospitalization, and medical conditions often associated with NOWS. In 3,526 infants with NOWS (restricted to gestational age ≥ 33 weeks), NOWS severity was associated with an increase in composite one-year utilization (OR: 1.1; 95% CI: 1.04-1.2) after adjusting for prematurity, sepsis, jaundice, use of antibiotics, infant sex, insurance status, race, hospital bed size, year of birth, and census division. In a subset of full-term infants (3008 with NOWS and 88,452 uncomplicated births), having a NOWS diagnosis was associated with higher odds of a 30-day (OR: 1.6; 95% CI: 1.03-2.4) and one-year rehospitalization (OR: 1.6; 95% CI: 1.1-2.4) after adjusting for infant sex, race, type of medical insurance, hospital location, census division, year of primary encounter, hospital bed size, and medical conditions. This study found higher healthcare utilization during the first year of life in infants diagnosed with NOWS, especially those with severe NOWS. Findings suggest a need for closer post-discharge follow-up and management of infants with NOWS.

Clinical pharmacology and dosing regimen optimization of neonatal opioid withdrawal syndrome treatments

In this paper, we review the management of neonatal opioid withdrawal syndrome (NOWS) and clinical pharmacology of primary treatment agents in NOWS, including morphine, methadone, buprenorphine, clonidine, and phenobarbital. Pharmacologic treatment strategies in NOWS have been mostly empirical, and heterogeneity in dosing regimens adds to the difficulty of extrapolating study results to broader patient populations. As population pharmacokinetics (PKs) of pharmacologic agents in NOWS become more well‐defined and knowledge of patient‐specific factors affecting treatment outcomes continue to accumulate, PK/pharmacodynamic modeling and simulation will be powerful tools to aid the design of optimal dosing regimens at the patient level. Although there is an increasing number of clinical trials on the comparative efficacy of treatment agents in NOWS, here, we also draw attention to the importance of optimizing the dosing regimen, which can be arguably equally important at identifying the optimal treatment agent.

Neonatal Opioid Withdrawal Syndrome (NOWS): A Transgenerational Echo of the Opioid Crisis

The incidence of neonatal opioid withdrawal syndrome (NOWS) has increased substantially in the setting of the opioid epidemic, a major public health problem in the United States. At present, NOWS has commonly used assessment and treatment protocols, but new protocols have questioned old practices. However, because of limited access to opioid use disorder (OUD) treatment and socioeconomic factors, many pregnant (and postpartum) women with OUD do not receive treatment. The pathophysiology of NOWS is not completely understood, although limited research studies have been conducted in humans and animals to better understand its etiology. Moreover, there is evidence that epigenetic and genetic factors play a role in the development of NOWS, but further study is needed. Animal models have suggested that there are deleterious effects of in utero opioid exposure later in life. Clinical research has revealed the harmful long-term sequelae of NOWS, with respect to cognitive function and childhood development. Many psychiatric disorders begin during adolescence, so as infants born with NOWS approach adolescence, additional clinical and molecular studies are warranted to identify biologic and psychosocial risk factors and long-term effects of NOWS. Additionally, access to specialized OUD treatment for pregnant women must be more readily available in the United States, especially in rural areas.

Evaluating Definitions for Neonatal Abstinence Syndrome

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.

Definitions of neonatal abstinence syndrome in clinical studies of mothers and infants: an expert literature review

Neonatal abstinence syndrome (NAS) results from discontinuation of in utero exposures to opioids/substances. The rising incidence of NAS has prompted an increased need for accurate research and public health data. To examine how NAS has been defined in clinical studies of opioid-exposed mothers and infants, a review process was developed based on the RAND/UCLA Appropriateness Method, yielding 888 abstracts. Per inclusion criteria, 57 abstracts underwent full-text review. To define NAS, studies cited using modified versions of the Finnegan NAS scoring tool (n = 21; 37%), ICD-9/10 coding (n = 17; 30%), original Finnegan tool (n = 16; 28%), Eat Sleep Console (n = 3; 5%), and Lipsitz (n = 3; 5%) tools, (3 cited 2+ tools). Most studies utilized subjective NAS scoring/assessment algorithms and neonatal coding as key elements defining NAS. While most cited opioid exposure as integral to their inclusion criteria, 26% did not. These approaches highlight the need for a more refined and standardized definition of NAS.

Developmental Outcomes of Children Born with Neonatal Abstinence Syndrome (NAS): A Scoping Review

AIMS

The purpose of this scoping review is to provide an overview of developmental outcomes of children diagnosed with neonatal abstinence syndrome (NAS).

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework was used to guide this scoping review. A comprehensive search of CINAHL, MEDLINE, EMBASE, Web of Science, and PsycINFO was conducted using search terms related to NAS and developmental areas. Full-text screening was completed for 30 articles, and eight studies were included in this review.

RESULTS

Cognitive and language development, as well as school performance, social and motor domains, may be areas of concern in children with NAS.

CONCLUSIONS

The developmental outcomes of infants with NAS cannot be firmly determined due to inconsistent results across reviewed studies. Future research investigating development across various ages is required for rending more appropriate intervention services to this high-risk population.

Development and validation of the Neonatal Abstinence Syndrome Minimum Data Set (NAS-MDS): a systematic review, focus group discussion, and Delphi technique

OBJECTIVES

Neonatal abstinence syndrome (NAS) is a combination of symptoms in infants exposed to any variety of substances in utero. Information systems and registries help to collect information about these patients; however, there is always a deep gap between complete and accurate information to be collected, understood, and applied in the health care system; thus, defining a minimum data sets (MDS) as one of the primarily steps of designing a registry system is essential. The aim of this study was to develop an MDS of the registry for infants with NAS in Iran.

METHODS

This research is a descriptive cross-sectional study. In this study, three steps were carried out to develop the MDS including systematic review, Delphi technique, and focus group discussion. A systematic review was conducted in relevant databases to identify appropriate related data. In the second phase, a focus group discussion was used to classify the extracted data elements by contributing neonatologists. Finally, data elements were chosen through the decision Delphi technique in two distinct rounds. Collected data were analyzed using SPSS 22 (SPSS Inc., Chicago, IL).

RESULTS

By reviewing related papers and available NAS registries in other countries, 145 essential data elements were identified. They were classified into two main categories based on the eight experts' opinions including maternal with two sections and infant with two sections. After applying two rounds of Delphi technique, the final data elements for maternal and infant categories were 42 and 31, respectively. Thus, on completion of the survey, 73 data elements were approved.

CONCLUSION

The proposed MDS for NAS can help to store an accurate and comprehensive data, document medical records, integrate them with other information systems and registries, and communicate with other healthcare providers and healthcare centers. This MDS can contribute to the provision of high-quality care and better clinical decisions.

"Alcohol During Pregnancy? Nobody Does That Anymore": State Legislators' Use of Evidence in Making Policy on Alcohol Use in Pregnancy

OBJECTIVE

In recent years, U.S. states have passed many laws addressing alcohol use in pregnancy, despite limited evidence on the impact of such policies. This study explores how state legislators use evidence when making policy on alcohol use in pregnancy.

METHOD

Study data are drawn from semistructured interviews with 29 state lawmakers and their aides in Maryland, North Carolina, and Virginia, conducted in March through July 2017. Interview transcripts were coded and analyzed by inductive and deductive methods.

RESULTS

Despite evidence on the harms of alcohol use in pregnancy, most lawmakers did not express concern about this topic. Instead, they expressed concern about opioid use in pregnancy. Personal experiences, anecdotes, and known contacts influenced legislators' views on substance use in pregnancy, whereas evidence, for the most part, did not. The intermediaries who typically bring evidence about problems and solutions to legislators did not appear to be raising the issue of alcohol use in pregnancy on legislators' agenda.

CONCLUSIONS

Basic evidence on the prevalence and harms of alcohol use in pregnancy did not appear to influence state lawmakers' policy priorities. Concern over opioid use in general may provide a window of opportunity to educate legislators on the relative scope and harms of alcohol and opioid use in pregnancy. It remains unclear why states are passing alcohol-in-pregnancy policies. More research is needed to explore how state lawmakers form their understanding of substance use in pregnancy and related policies.

Treatment for substance use disorders in pregnant women: Motivators and barriers

BACKGROUND

Pregnancy is a unique opportunity to provide broad and necessary medical care for women- including treatment for Substance Use Disorders (SUD). The standard of care for SUD in pregnant women is treatment at a comprehensive care facility. There is little existing qualitative research exploring what brings pregnant women with SUD to treatment and what barriers to treatment exist for this population. This study explored women's self-reported reasons for pursuing treatment or hesitating to do so.

METHODS

This qualitative study used interviews to explore common factors that motivate pregnant women with SUD to seek comprehensive care during pregnancy and common hesitations/ barriers to treatment. The study population included 20 women in treatment at a comprehensive care facility for pregnant and parenting women at Johns Hopkins. Participants volunteered to do interviews which were recorded and transcribed for analysis.

RESULTS

Interviews revealed several major themes in motivators to seek treatment: readiness to stop using, concern for the baby's health, concern about custody of the baby or other children, wanting to escape violent environments or homelessness, and seeking structure. Barriers to treatment included fear of loss of custody, not wanting to be away from children/partner, concern about stigma or privacy, and lack of childcare and transportation.

CONCLUSIONS

This study revealed common motivators to seek treatment and barriers to treatment for pregnant women with SUD. These themes may help direct future studies and guide efforts to increase access to crucial care in this vulnerable population.