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Objectives: In 2019, the Council of State and Territorial Epidemiologists ratified a multitiered standardized surveillance case definition (SSCD) for neonatal abstinence syndrome (NAS) to minimize variability in definitions across states. This evaluation of the tier 1 NAS SSCD aimed to identify common challenges and opportunities for enhancement to support consistent implementation of the definition. Methods: This mixed-methods analysis consisted of 3 virtual focus groups in March 2021 with site principal investigators, medical record abstractors, and data analysts (1 focus group each) from 4 jurisdictions piloting the tier 1 NAS SSCD. We analyzed focus group transcripts to create a codebook. We collected written reports in February 2022 from the 4 jurisdictions, conducted thematic analysis of focus group transcripts and written reports to identify themes, and collected surveillance data on infants identified with NAS born from January 2020 through December 2021 from the pilot sites. We analyzed surveillance data to further inform identified themes. We examined agreement among tier 1 classifications assigned independently by each pilot site and the Centers for Disease Control and Prevention to cases of NAS. Results: Three major themes emerged in the data: challenges abstracting data on withdrawal signs from the medical record, difficulty determining the time frame of prenatal substance exposure, and challenges assigning case classifications. In a comparison of tier 1 classifications assigned by the Centers for Disease Control and Prevention and the sites, 82.1% of cases in the dataset were concordant. Conclusions: We identified several opportunities to modify the SSCD to promote consistency and ease implementation across jurisdictions. Promoting consistent implementation supports comparability of NAS incidence estimates across jurisdictions, evaluation of prevention efforts, and allocation of resources to support families. [ABSTRACT FROM AUTHOR]

Compared with the Finnegan Neonatal Abstinence Scoring System (FNASS), the Eat, Sleep, Console (ESC) approach reduces pharmacotherapy and length of stay (LOS) for neonatal opioid withdrawal syndrome (NOWS) infants. The independent outcome contribution of ESC is unknown as the approach combines ESC assessment with additional management changes. Our objective was to evaluate ESC assessment's independent impact on outcomes compared with FNASS. We conducted a retrospective cohort study of in utero opioid-exposed infants ≥35 weeks gestation managed with FNASS versus ESC. Outcomes included pharmacotherapy initiation, LOS, length of pharmacotherapy, and emergency department visit/readmissions. Among 151 FNASS and 100 ESC managed infants, pharmacotherapy initiation (P =.47), LOS for all infants (P =.49), and LOS for pharmacologically treated infants (P =.68) were similar. Length of pharmacotherapy did not differ (P =.84). Emergency department evaluation/NOWS readmission was equally rare (P =.65). Using equivalent models of care, comparison of ESC and FNASS assessment tools showed no difference in NOWS outcomes. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: The opioid epidemic has led to a surge in diagnoses of neonatal opioid withdrawal syndrome (NOWS). Many states track the incidence of NOWS by using the P96.1 International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code for "neonatal withdrawal symptoms from maternal use of drugs of addiction." In October 2018, an ICD-10-CM code for neonatal opioid exposure (P04.14) was introduced. This code can be used when an infant is exposed to opioids in utero but does not have clinically significant withdrawal symptoms. We analyzed the effect of the P04.14 code on the incidence rate of NOWS (P96.1) and "other" neonatal drug exposure diagnoses (P04.49). Methods: We used private health insurance data collected for infants in the United States from the first quarter of 2016 through the third quarter of 2021 to describe incidence rates for each code over time and examine absolute and percentage changes before and after the introduction of code P04.14. Results: The exclusive use of code P96.1 declined from an incidence rate per 1000 births of 1.08 in 2016-2018 to 0.70 in 2019-2021, a −35.7% (95% CI, −47.6% to −23.8%) reduction. Use of code P04.49 only declined from an incidence rate of 2.34 in 2016-2018 to 1.64 in 2019-2021, a −30.0% (95% CI, −36.4% to −23.7%) reduction. Use of multiple codes during the course of treatment increased from an average incidence per 1000 births of 0.56 in 2016-2018 to 0.79 in 2019-2021, a 45.5% (95% CI, 24.8%-66.1%) increase. Conclusion: The introduction of ICD-10-CM code P04.14 altered the use of other neonatal opioid exposure codes. The use of multiple codes increased, indicating that some ambiguity may exist about which ICD-10-CM code is most appropriate for a given set of symptoms. [ABSTRACT FROM AUTHOR]

The article focuses on a 5-day-old baby girl in the NICU exposed to HIV, syphilis, and maternal drug use, presenting with diarrhea possibly due to neonatal abstinence syndrome. Topics include the infant's treatment regimen for HIV prophylaxis and withdrawal symptoms, along with the management of a rash possibly caused by nevirapine, leading to a change in medication and successful completion of prophylactic treatment before discharge.

Introduction: Children born with neonatal abstinence syndrome (NAS) have lower rates of preventive care utilization than children born without NAS, a pattern which is only partially explained by differences in social determinants of health (SDH). We sought to determine whether SDH and clinical characteristics were associated with well-child visit (WCV) attendance among children born with NAS in a rural academic health system. Methods: Infants born at a single hospital in 2016–2018 were retrospectively included if they were diagnosed with non-iatrogenic NAS attributable to in utero opioid exposure and established care with an affiliated primary care clinic by 6 months of age. Healthcare utilization was tracked through the first 12 months of life. Independent variables included demographics, prenatal risk factors, insurance coverage, and SDH such as housing problems and food insecurity. Ages and Stages Questionnaire (ASQ) scores were extracted from the latest completed WCV during the first year of life. Results: We identified 182 patients with NAS, of whom 80 established care with the primary care clinic, with a median of four WCVs (interquartile range: 2, 5) completed by 12 months of age. On unadjusted Poisson regression, none of the demographic, clinical, or SDH characteristics were associated with the number of completed WCVs. Among 44 patients with available ASQ data, the number of WCVs was not associated with ASQ scores at the latest WCV. Conclusions: Within an academic rural health system, SDH and other infant or family characteristics did not predict WCV attendance among infants with NAS. [ABSTRACT FROM AUTHOR]

Background: Infants born to mothers with opioid use disorder (OUD) and prenatally treated with buprenorphine have a significantly lower incidence of neonatal opioid withdrawal syndrome (NOWS), its treatment duration, and hospital length of stay compared with methadone. However, risk of NOWS remains and clinicians continue to lack an objective methodology to predict NOWS severity among these infants. Objective: The purpose of this study was to assess the relationship between buprenorphine exposure, umbilical cord tissue (UCT) concentrations, and NOWS development and severity. Methods: A single-center retrospective observational cohort study from March 2018 through June 2020 of newborns exposed to buprenorphine in utero. Associations between quantified buprenorphine exposure, neonatal UCT concentrations, NOWS diagnosis, and severity were made using regression analyses. Results: A total of 24 mothers and 25 neonates were included. Length of maternal buprenorphine therapy (months) positively correlated to norbuprenorphine (r 2 = 0.234, P = 0.019) and buprenorphine + norbuprenorphine UCT concentrations (r 2 = 0.203, P = 0.031). A positive relationship was seen between active metabolite concentrations and cumulative morphine dose (mg/kg) for treatment of severe NOWS (r 2 = 0.471, P = 0.007). A 0.36 ng/g buprenorphine + norbuprenorphine UCT (CI = 0.002-0.72, P = 0.049) equated in a 1-point increase in modified peak Finnegan score. Conclusion and Relevance: Buprenorphine and norbuprenorphine UCT concentrations can allow for quantification of in utero fetal exposure and demonstrate an association with a longer duration of exposure with the severity and treatment of NOWS in exposed infants. [ABSTRACT FROM AUTHOR]

Mary Anne is pleased that Shayla is beginning to trust her and knows that she needs to continue to build their relationship to best serve Jax and Shayla's needs. The third related DEC RP for practitioners who work with infants with NAS and their families is DEC RP INS13, which recommends using coaching or consultation strategies to facilitate positive adult-child interactions ([7]). Use Coaching Strategies With Families (DEC RP INS13) Once practitioners have trusting relationships with families, they can coach families in effective strategies for responding to their infants with NAS, as indicated by DEC RP INS13 ([7]). To address this need, three DEC (DEC) of the Council for Exceptional Children Recommended Practices (RPs) can support practitioners' work with families of children with NAS ([7]): Family-centered practice (DEC RP F1). [Extracted from the article]

Background: Intentional or accidental drug-overdose is a leading cause of mortality in U.S. women of child-bearing age. Opioid use during pregnancy is not only associated with maternal overdose, but with low birth weight at term and neonatal abstinence syndrome (NAS). Buprenorphine was approved as a medication for opioid use disorder (MOUD) in the United States in 2002 and is for many women, a preferred treatment option versus methadone. Buprenorphine is relatively safe during pregnancy and is associated with lower rates of NAS than methadone. Given the importance of MOUD during pregnancy, relatively little information exists regarding patients' questions and concerns about buprenorphine treatment, including the psychological challenges they face. Aims: The purpose of the study was to describe the perinatal concerns of women with opioid use disorder who posted to an online suboxone forum. Methods: Qualitative descriptive design to analyze some 170 posts from mothers with OUD to an online Suboxone® support forum over the period 2016–2021. Results: The analysis of the interview data revealed 4 important themes: (a) Stigma resulting in self-deprecation, low self-esteem, and low self-efficacy; (b) stigma from family members and loved ones; (c) stigma from the medical profession; and (d) stigma from the community at-large (social stigma). Conclusions: There is compelling evidence to emphasize the importance of open communication and support between medical personnel and patients to ensure optimal outcomes for mother and baby. [ABSTRACT FROM AUTHOR]

The article presents the discussion on neonatal abstinence syndrome (NAS) encompassing a constellation of symptoms newborns. Topics include certain geographic areas more affected than others, specifically areas with high food insecurity and public health insurance–dependent populations; and examining methadone and metabolite levels in blood and meconium not correlated to symptomatology in infants.

Objective: Laryngomalacia (LM) is the most common congenital anomaly of the larynx. The cause of LM is still largely unknown, but a neurological mechanism has gained the most acceptance. There have not been any studies examining the prevalence of LM in infants with Neonatal Abstinence Syndrome (NAS). The aim of our study is to determine if infants with NAS are more likely to be diagnosed with LM. Methods: This study was a population-based inpatient registry analysis. We examined nationwide neonatal discharges in 2016 using the Kids' Inpatient Database (KID). Only patients listed as neonates were included. The International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) codes for neonatal withdrawal symptoms from maternal use of drugs of addiction (P96.1) and diagnoses denoting LM were used. To quantify associations between the LM and NAS groups, prevalence rates and odds ratios (ORs) were used. Results: There were 3 970 065 weighted neonatal discharges in the 2016 KID. Among patients included in our dataset, 0.809% (32 128) had NAS and 0.075% (2974) had LM. There was an increased odds ratio for neonates with NAS and LM (OR of 2.85, 95% CI = 2.24-3.63) compared to infants without NAS. Multiple logistic regression accounting for possible confounders produced an adjusted OR of 1.68 (95% CI = 1.29-2.19). Conclusion: Our study found an association between NAS and LM. This suggests that prenatal exposure to opioids or possibly the sequelae of withdrawal symptoms may be risk factors for the development of LM. [ABSTRACT FROM AUTHOR]

Background: Kratom (Mitragyna speciosa) consumption and associated health effects have raised debates in the United States. Although most people using this herb do not experience adverse health effects associated with kratom use, medical providers should be knowledgeable of emerging substances and concurrent, sequential, or simultaneous use of other drugs which may impact healthcare recommendations and prescribing practices. Methods: The objective of this narrative review was to elucidate selected health effects associated with using kratom—either alone or with other substances. Since scientifically controlled human subjects research on kratom use is still limited, relevant case reports were also described. Results: Cardiovascular, gastrointestinal, neurological, and psychiatric effects associated with kratom use were especially notable, and in-utero exposure accompanied concern regarding a neonate's risk for developing neonatal abstinence syndrome. Our ability to identify and understand the role of this herb in kratom-associated fatalities is complicated since kratom is not routinely screened for in standard forensic toxicology. If a screening is performed, it is usually for the major alkaloid, mitragynine, as a surrogate for kratom use. In addition to lacking a standard practice of screening decedents for kratom alkaloids, the association between mortality and kratom use may be confounded by polysubstance use, adulteration of kratom products, and drug-herb interactions. Conclusions: Increasing medical awareness of this herb is vital to ensuring prompt administration of best-practice medical advice or treatment for people seeking information related to kratom use or for patients experiencing an adverse health effect that may be associated with using or withdrawing from kratom. Knowledge gained from continued surveillance and study of kratom and its associated health effects may assist in guiding clinical decision-making and preventing development of adverse health effects among people using kratom. [ABSTRACT FROM AUTHOR]

Objective: This study examines phenotypic presentation and perioperative outcomes of cleft-related procedures for infants with cleft lip and/or palate (CL/P) and prenatal opioid exposure. Design: This is a retrospective review of infants with prenatal opioid exposure treated for CL/P from 2008 to 2018. Setting: Patients cared for at a tertiary center from 2008 to 2018. Patients/Participants: Eighteen patients with documented prenatal opioid exposure and CL/P had primary repairs in our unit. Main Outcome Measure(s): The phenotypes of CL/P were characterized. Demographic data regarding additional exposures, as well as associated medical and social comorbidities were recorded. Outcome variables included operative delays, perioperative complications, and loss of follow-up. Results: Isolated cleft palate (CP; 67%) was overrepresented among patients with prenatal opioid exposure and CL/P, as was Robin sequence (50% in isolated CP). Fifty-six percent had exposure to additional substances. A majority (67%) had other medical conditions or anomalies, and 17% had known genetic syndromes. Seventy-two percent were in state custody. Thirty-nine percent of exposed patients had delays in their planned operative dates due to medical and/or social factors. There were no postoperative readmissions following cleft procedures. Lack of follow-up was noted in 33% of patients. Conclusions: Infants with CL/P who have prenatal opioid exposure are likely to have additional medical conditions and complex social challenges. [ABSTRACT FROM AUTHOR]

Objective: To determine the prevalence and odds ratios for cleft lip and/or palate (CL/P) among infants prenatally exposed to opioids with or without neonatal opioid withdrawal syndrome (NOWS). Design: This study represents an exploratory, retrospective cohort study design of newborn medical health records from 2011 to 2016. Setting: Records were drawn from a regional health system located in South Central Appalachia. Population and Study Sample: The original population yielded 3 cohorts of infants: (1) infants with opioid exposure (OE) but not requiring pharmacological intervention (OE; N = 168); (2) infants with NOWS requiring pharmacological intervention (N = 294); and (3) infants with no opioid exposure (NOE; N = 16 090), the primary comparison group. Main Outcome: Infants in the NOWS and OE groups showed significantly increased prevalence and odds ratios for CL/P when compared to those in the NOE group. Results: Prevalence rates per 1000 live births for infants with OE (35.71) and infants with NOWS (6.80) were significantly higher than those for infants with NOE (1.37). Comparison of infants with OE to the NOE group revealed significantly increased odds for CL/P, isolated cleft palate (CP), cleft lip (CL), and cleft lip and palate (CLP) (27.05, 41.81, 19.26, 19.37, respectively; all P s <.008). The odds ratios for infants with NOWS compared to the NOE group were significantly higher for CL/P and CP (5.00 and 10.98, respectively; P s <.03) but not for CL and CLP. Conclusion: The results provide additional evidence that prenatal OE should be considered among the critical environmental risk factors that can contribute to CL/P. [ABSTRACT FROM AUTHOR]

The rising prevalence of opioid use disorder (OUD) among those living in the United States has demanded a collaborative response from health care and policy spheres. Addressing OUD among pregnant women is especially difficult, given the controversies surrounding the medical and ethical balance between meeting maternal versus fetal/newborn needs. Most medical organizations discourage the criminalization of drug use in pregnancy due to the adverse public health outcomes of such an approach. Despite this recommendation, many states continue to use punitive law to address drug use in pregnancy. In 2014, the Fetal Assault Law in Tennessee (TN) became the first law in the United States to directly allow women to be prosecuted for drug use in pregnancy. Since its expiration in 2016, this law has been re-introduced several times to the TN legislature in support of permanent implementation. This article outlines the impact of the initial Fetal Assault Law on maternal/newborn health in TN and provides alternative immediate, short-term, and long-term health policy strategies through which health care providers and legislators can better advocate for the well-being of both mothers with OUD and their infants. [ABSTRACT FROM AUTHOR]

In 2016, federal law changed state child welfare mandates related to prenatally substance-exposed infants. Little is known regarding the status or implications of policy implementation. The current study examined thematic clusters among states' policies responsive to this 2016 mandate. Cluster analysis identified four distinct categories of states' implementation: (1) "innovators/early adopters," (2) "early majority," (3) "late majority," and (4) "laggards." Innovator/early adopter states (n = 14) were most likely to have implemented plan of safe care policies consistent with Child Abuse Prevention and Treatment Act (CAPTA). Early majority states (n = 15) have started developing some aspects of CAPTA 2016 but have some aspects that are still in development. Late majority states (n = 17) have adopted few aspects of CAPTA 2016 but had implemented more CAPTA 2003 and 2010 aspects than states in the laggard cluster. Laggard states (n = 6) have implemented the fewest CAPTA prenatal substance exposure domains. In bivariate analyses, the only variable associated with clusters was Census region (e.g., New England), suggesting that states' implementation decisions may be influenced by their regional neighbors. [ABSTRACT FROM AUTHOR]

Purpose: As almost nine in ten pregnancies among women with opioid use disorder (OUD) are unintended, expanding access to contraception is an underutilized but potentially effective strategy in increasing reproductive agency and reducing the overall burden of neonatal abstinence syndrome. We aimed to identify where and how contraceptive services could be integrated into existing points-of-contact for women with OUD. Approach: In-depth qualitative interviews. Setting: Three diverse catchment areas in Missouri. Participants: Women with OUD (n = 15) and professional stakeholders (n = 16) representing five types of existing OUD service points: syringe exchange programs, recovery support programs, substance use treatment programs, emergency departments, and Federally Qualified Health Centers. Method: Interviews were audio-recorded, transcribed, and thematically coded using Dedoose software. Results: Six themes emerged as essential components for integrating contraceptive services into existing points-of-contact for women with OUD: (1) reach women with unmet need; (2) provide free or affordable contraception; (3) maximize service accessibility; (4) provide patient-centered care; (5) employ willing, qualified contraceptive providers; and (6) utilize peer educators. Participants affirmed the overall potential benefit of contraceptive service integration and illuminated various opportunities and challenges relevant to each type of existing service point. Conclusion: As health promotion initiatives look to increase access to contraception among women with OUD, these six' participant-identified components offer essential guidance in selecting advantageous points-of-contact and addressing remaining gaps in services. [ABSTRACT FROM AUTHOR]

Objectives: The prevalence of opioid use disorder continues to rise in the United States, with a simultaneous increase in the diagnosis of both opioid use disorder during pregnancy and neonatal opioid withdrawal syndrome. Despite these increases in pregnancy-related care, little is known about hospital policy and policy implementation related to opioid use disorder in pregnancy. In addition, it is unknown whether policies might differ in rural or urban hospitals. To better examine these issues, Minnesota hospitals were surveyed regarding the existence and implementation of policies related to opioid use disorder in pregnancy and whether any policy implementation challenges had been identified. Methods: From August to December 2017, the research team contacted all Minnesota hospitals that offered obstetric services (n = 82) to survey challenges to implementing policies for opioid use disorder during pregnancy, among other questions. Fifty-nine hospitals had respondents (primarily obstetric department supervisors) who provided information about policy implementation challenges for a 72% response rate. Qualitative responses were analyzed using qualitative description and according to hospital location: metropolitan (urban), micropolitan (rural), or non-core (rural). Results: Ninety-one percent of respondents said that they had pregnancies affected by opioid use disorder at their hospital within the last year. Four major challenges to policy implementation were identified in qualitative responses: (1) provider consensus, (2) patient response to policy, (3) lack of resources, and (4) low frequency of occurrence. All four challenges were more frequently identified by respondents at rural hospitals compared to urban hospitals. Conclusion: This study identified challenges in standardizing hospital care for pregnancies affected by opioid use disorder, and these challenges were identified more frequently in rural locations. These non-urban hospitals may require increased state and federal support and funding. [ABSTRACT FROM AUTHOR]

The authors highlight four key findings of a collaborative effort that the U.S. Department of Health and Human Services leads with national experts and describe implications for national policy for neonatal abstinence syndrome or neonatal opioid withdrawal syndrome (NAS/NOWS). Topics mentioned include a one-day national convening on NAS/NOWS in Philadelphia, Pennsylvania, strategies to support opioid-exposed mothers and infants, and interoperability in leveraging health information technology.

Neonatal abstinence syndrome (NAS) is a public health issue that affected more than 2% of live births in Kentucky in 2017. We analyzed data from Kentucky’s early intervention (EI) program and the mandatory statewide NAS registry to learn more about how families of children with NAS utilize EI services. Out of 1,113 children in the study, 32% were referred to EI and 9% enrolled. Gaps in the intake process include low referral rates, low screening rates among referred children (36%), and lag in the time from referral to enrollment. Because 79% of screened children qualified for EI and 95% of qualifying children enrolled, this sample demonstrated some need for and interest in services. We are using these findings to inform policy recommendations that could help EI agencies experiencing an influx of potential clients with a history of NAS. [ABSTRACT FROM AUTHOR]

Objectives: Between 2003 and 2013, the rate of neonatal abstinence syndrome (NAS)—a postnatal drug withdrawal syndrome—in Tennessee increased approximately 10-fold. NAS surveillance is relatively new, and underestimation associated with surveillance has not been described. We compared data from the Tennessee NAS public health surveillance system (TNSS) with a second source of NAS data, hospital discharge data system (HDDS), and estimated the true number of infants with NAS using capture-recapture methods. Methods: We obtained NAS data on cases of NAS among Tennessee infants from TNSS and HDDS from January 1, 2013, through December 31, 2016. We matched cases of NAS identified in TNSS to cases identified in HDDS. We estimated the true number of infants with NAS by using the Lincoln-Peterson estimator capture-recapture methodology. Results: During the study period, 4070 infants with NAS were reported to TNSS, and 5321 infants with NAS were identified in HDDS; 2757 were in both data sets. Using capture-recapture methods, the total estimated number of infants with NAS during the study period was 7855 (annual mean = 1972; estimated range = 1531-2427), which was 93% more than in TNSS and 48% more than in HDDS. Drugs used for the medication-assisted treatment of substance use disorder were the most commonly reported substances associated with NAS (n = 2389, 59%). Conclusions: TNSS underestimated the total burden of NAS based on the capture-recapture estimate. Case-based public health surveillance is important for monitoring the burden of and risk factors for NAS and helping guide public health interventions. [ABSTRACT FROM AUTHOR]

Opioid use during pregnancy is on the rise in the United States. Neonatal abstinence syndrome (NAS), also known as newborn drug withdrawal, is a public health epidemic. Between 2004 and 2014, Tennessee experienced a fivefold increase in NAS hospitalizations, from 1.5 to 8.0 per 1,000 live births. Soaring increases in the number of newborns with NAS nationwide have caught the attention of many federal and state lawmakers, especially given the unknown burdens associated with medical and social services needed by those affected over time. Tennessee opioid-related regulations and laws enacted between 2000 and 2018 were systematically reviewed and analyzed to identify each law's purpose; effects on families and individuals; pros and cons in terms of social, practical, and legal factors; and implications for nursing practice. Our findings were that Tennessee's laws are intended to decrease the number of opioids prescribed, ensure access to continued prenatal care and substance abuse management for mothers with substance use disorders, and reduce the ease of obtaining opioids. We also found that Tennessee lawmakers have enacted laws and regulations aimed at decreasing the abuse of opioids, but not reducing the incidence of NAS. As new laws are considered, it is critical that health care providers and lawmakers work together to ensure that the developed and enacted laws strike a balance between safely managing the care of both pregnant women and their newborns without producing negative outcomes. [ABSTRACT FROM AUTHOR]

We tested the hypothesis that Modified Finnegan Neonatal Scoring System (MFNSS) scores can guide early discharge at 72 hours for newborns at risk for neonatal abstinence syndrome (NAS). A retrospective cohort study with a primary outcome of early discharge of newborns at risk for NAS using mean MFNSS scores recorded before pharmacologic treatment was performed. Quantile regression was used to develop percentile curves of mean MFNSS scores. A total of 202 term newborns at risk for NAS with 5066 mean MFNSS scores recorded before pharmacologic treatment were studied. Sixty-eight of 121 (56%) newborns not treated at 72 hours had mean MFNSS scores <50th percentile and only 1 was ultimately treated (1.5%, 95% confidence interval: 0% to 8%). No newborns with mean MFNSS scores <25th percentile at 72 hours were treated. Newborns at risk for NAS with mean MFNSS scores <50th percentile can be safely discharged by 72 hours if families can assure close outpatient follow-up. [ABSTRACT FROM AUTHOR]

The incidence of perinatal opioid use and neonatal withdrawal continues to rise rapidly in the face of the growing opioid addiction epidemic in the United States, with rural areas more severely affected. Despite decades of research and development of practice guidelines, maternal and neonatal outcomes have not improved substantially. This focused ethnography sought to understand the experience of accessing care necessary for substance use disorder recovery, pregnancy, and parenting. Personal accounts of 13 rural women, supplemented by participant observation and media artifacts, uncovered three domains with underlying themes: challenges of getting treatment and care (service availability, distance/geographic location, transportation, provider collaboration/coordination, physical and emotional safety), opportunities to bond (proximity, information), and importance of relationships (respect, empathy, familiarity, inclusion, interactions with care providers). Findings highlight the need for providers and policy makers to reduce barriers to treatment and care related to logistics, stigma, judgment, and lack of understanding of perinatal addiction. [ABSTRACT FROM AUTHOR]

Increasing opiate use among women of reproductive age has led to a rise in adverse pregnancy outcomes, including neonatal abstinence syndrome (NAS). Recent studies have documented the increased incidence of NAS, but subsequent impact on the chain of organizations within the social service system remains unexplored. In this article, we begin to estimate the reach of this issue by assessing the labor costs of caring for NAS infants within the Massachusetts Department of Children and Families (MA DCF). Based on a process map of services, we modeled social service hours using encounter-level hospital data as inputs. In this manner, we estimate that MA DCF professionals now devote more than 10,000 hours per month to this single problem. As opiate addiction increases across America, substantial additional investment in social service providers, foster care, Early Intervention Programs, and other family services will be required. [ABSTRACT FROM AUTHOR]

The article discusses a study on the impact of infant massage on neonatal abstinence syndrome. It explores its effects on babies' behavior and the mothers' relationship with their babies who develop withdrawal symptoms from opioid use following birth. It states that the massage brings calm and comfort, empowerment, and enjoyment and bonding.

Current estimates of the prevalence of opioid withdrawal in newborns from the 2012 Better Outcomes Registry and Network Ontario reveal that more than 4 births per 1000 display recognizable symptoms of neonatal abstinence syndrome (NAS). With a growing consensus surrounding aspects of newborn opioid withdrawal care, clinicians might agree that all infants exposed to maternal opioids require supportive observation and care to ensure appropriate adaptation and growth in the newborn period and, likewise, that there exists a smaller percentage of newborns who require additional pharmacotherapy. However, due to the dearth of comparative studies of NAS tools, there remains a lack of evidence to support the use of a specific NAS method of scoring or treatment. Two types of NAS treatment protocols currently in use include a symptom-only versus weight-based protocols. Our Neonatal Intensive Care Unit (NICU) has used both models. A formal structured NAS tool and weight-based morphine delivery system began in our NICU in 1999. We audited all newborns with known exposure to maternal opioids in our NICU from the years 2000 to 2014. The Finnegan scoring tool was used throughout all years of the chart audit. Modifications made to the Finnegan scoring tool from the MOTHER study were adapted for use in our NICU at the same time as adopting the Johns Hopkins model of symptom-only based morphine delivery in 2006. The objective of this comparative study using a retrospective chart audit is to compare length of stay (LOS) and total accumulative morphine dose across these two morphine delivery protocols. Our audit revealed that there were a significantly higher proportion of newborns in the symptom-only model that received morphine and, perhaps accordingly, also had a significantly higher LOS compared to those in the weight-based model. Comparing only those infants who did receive morphine, the comparative total accumulative dose of morphine and LOS were not significantly different between the weight-based and symptom-only morphine delivery models. [ABSTRACT FROM AUTHOR]

BACKGROUND: Untreated opioid dependence in pregnant women is associated with adverse birth outcomes. Buprenorphine and methadone are options for opioid agonist medication-assisted treatment during pregnancy. OBJECTIVE: The aim of this study was to describe adverse birth outcomes observed with buprenorphine or methadone treatment compared to the general population in Sweden. METHODS: Pregnant women and their corresponding births during 2005-2011 were identified in the Swedish Medical Birth Register. Data on stillbirth, neonatal/infant death, mode of delivery, gestational age at birth, Apgar score, growth outcomes, neonatal abstinence syndrome, and congenital malformations were examined. Frequencies were compared using two-sided Fisher's exact tests. Unadjusted estimates of birth outcomes for women treated with buprenorphine or methadone were compared to the registered general population. RESULTS: A total of 746,257 pregnancies among 538,178 unique women resulted in 746,485 live births. Among the 194 women treated with buprenorphine (N = 176) or methadone (N = 52), no stillbirths or neonatal/infant deaths occurred. Neonatal abstinence syndrome developed in 23.3% and 38.5% of infants born to mothers treated with buprenorphine and methadone, respectively. The frequency of the selected adverse birth outcomes assessed in women treated with buprenorphine as compared to the general population was not significantly different. However, a significantly higher frequency of preterm birth and congenital malformations was observed in women treated with methadone as compared to the general population. Compared with the general population, methadone-treated women were significantly older than buprenorphine-treated women, and both treatment groups began prenatal care later, were more likely to smoke cigarettes, and did not cohabitate with the baby's father. CONCLUSIONS: An increased frequency of the selected adverse birth outcomes was not observed with buprenorphine treatment during pregnancy. Twofold increased frequency of preterm birth [2.21 (1.11, 4,41)] and congenital malformations [2.05 (1.08, 3.87)] was observed in the methadone group, which may be partly explained by older average maternal age and differences in other measured and unmeasured confounders. [ABSTRACT FROM AUTHOR]

In spite of the growing knowledge and understanding of addiction as a chronic relapsing medical condition, individuals with substance use disorders (SUD) continue to experience stigmatization. Pregnant women who use substances suffer additional stigma as their use has the potential to cause fetal harm, calling into question their maternal fitness and often leading to punitive responses. Punishing pregnant women denies the integral interconnectedness of the maternal-fetal dyad. Linking substance use with maternal unfitness is not supported by the balance of the scientific evidence regarding the actual harms associated with substance use during pregnancy. Such linkage adversely impacts maternal, child, and family health by deterring pregnant women from seeking both obstetrical care and SUD treatment. Pregnant women who use substances deserve compassion and care, not pariah-status and punishment. [ABSTRACT FROM AUTHOR]

A case study is presented of an infant born to a 28-year-old gravida 2, para 2 mother. Diagnosis of mother with gestational hypertension in triage; maternal urine drug screen showed positive for cocaine and opioids and developed neonatal abstinence syndrome. Further she was treated of hyperphagia in a full-term neonate due to neonatal abstinence syndrome.

Objective. Study aims to examine development in infants following prenatal heroin, methadone, and opioid exposure, which adversely affects central and autonomic nervous systems. Abrupt discontinuation results in neurologic and behavioral findings as Neonatal Abstinence Syndrome (NAS). Method. Following NAS treatment, 28 infants (mean age 55 days [range 21-98 days], 57% male) were assessed using Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) Cognitive, Language, and Motor subscales. Outcomes were compared with a historical control. Results. Mean Language and Cognition scores were significantly lower (P < .001) in the NAS group. Distributions of scores for Language (P < .001) and Cognition (P = .022) were also significantly different between NAS and historical control groups. Conclusion. Prenatal heroin, methadone, and other opioid exposure is associated with weaknesses in language and cognition. This information has important public health implications, drawing attention to an otherwise healthy infant population which may benefit from early intervention services. [ABSTRACT FROM PUBLISHER]

Mutations in the smooth muscle–specific isoform of α-actin (ACTA2) cause vascular smooth muscle dysfunction leading to aortic aneurysm and moyamoya syndrome. A unique R179H mutation in ACTA2 has been reported to result in widespread smooth muscle dysfunction affecting vascular and extravascular smooth muscles. We report a 7-year-old girl with an ACTA2 R179H mutation manifesting with neonatal seizures due to multifocal infarcts, asymmetric motor deficits, global developmental delay, spasticity, congenital bilateral mydriasis, and a large patent ductus arteriosus. Serial magnetic resonance imaging (MRI) of the brain over 7 years showed diffuse supratentorial white matter abnormalities consistent with a progressive leukoencephalopathy. Magnetic resonance angiography of the cerebral vessels showed stenosis in the terminal portion of the bilateral internal carotid arteries with fusiform dilation of the proximal segment. Neonatal onset of neurologic symptoms in ACTA2 mutations has not been previously reported. R179H mutation in ACTA2 represents the severe end of the disease spectrum. [ABSTRACT FROM AUTHOR]

Given that buprenorphine + naloxone is prescribed for opioid-dependent pregnant women, it is important to examine the extent to which it differs from buprenorphine alone, methadone, or methadone-assisted withdrawal on neonatal and maternal outcomes. Summary statistics on maternal and neonatal outcomes were collected from 7 previously published studies examining treatment for opioid-dependent pregnant women that represented a range of research methodologies. Outcomes from these studies were compared to the same outcomes for 10 women treated with the combined buprenorphine + naloxone product. There were no significant differences in maternal outcomes for buprenorphine + naloxone compared to buprenorphine, methadone, or methadone-assisted withdrawal. Preliminary findings suggest no significant adverse maternal or neonatal outcomes related to the use of buprenorphine + naloxone for the treatment of opioid dependence during pregnancy. However, further research should examine possible differences between buprenorphine + naloxone and buprenorphine alone or methadone in fetal physical development. [ABSTRACT FROM AUTHOR]

Feeding disorders and the association of neonatal feeding disorders with other outcomes were assessed in a cohort of 84 children with neonatal arterial ischemic stroke at a tertiary children's hospital. Both χ² tests and Fisher's exact test were used to test associations. Forty-one of 84 children (48.8%) had feeding difficulties. Infarcted vascular territory (unilateral vs bilateral, P = .24) and neonatal seizures (P = .39) were not associated with feeding problems. Children with at least 1 perinatal comorbidity (P = .002, odds ratio = 4.27; 95% confidence interval: 1.65-11.03) and specifically respiratory problems (P = .004, odds ratio = 3.85; 95% confidence interval: 1.49-9.93) were significantly more likely to have feeding problems. Neonatal feeding problems were predictive of feeding problems at 12 to 24 months of age (P = .026, odds ratio = 3.33; 95% confidence interval: 1.12-9.90) but did not predict speech delay (P = .97) or cerebral palsy (P = .70). Feeding problems are important sequelae of neonatal stroke, but neonatal feeding problems in this group do not predict speech delay or cerebral palsy. [ABSTRACT FROM AUTHOR]

Objective: To determine, by phenotypic and genotypic methods, oxacillin susceptibility in Staphylococcus aureus strains isolated from pediatric and neonatal intensive care unit patients seen at the University Hospital of the Botucatu School of Medicine. Methods: A total of 100 S. aureus strains isolated from the following materials were studied: 25 blood cultures, 21 secretions, 12 catheters, 3 cannulae and one chest drain from 62 patients in the neonatal unit, and 36 blood cultures, one pleural fluid sample and one peritoneal fluid sample from 38 patients in the pediatric unit. Resistance of the S. aureus isolates to oxacillin was evaluated by the disk diffusion method with oxacillin (1 μg) and cefoxitin (30 μg), agar screening test using Mueller-Hinton agar supplemented with 6 μg/ml oxacillin and 4% NaCl, and detection of the mecA gene by PCR. In addition, the isolates were tested for β-lactamase production using disks impregnated with Nitrocefin and hyperproduction of β-lactamase using amoxicillin (20 μg) and clavulanic acid (10 μg) disks. Results: Among the 100 S. aureus strains included in the study, 18.0% were resistant to oxacillin, with 16.1% MRSA being detected in the neonatal unit and 21.0% in the pediatric unit. The oxacillin (1 μg) and cefoxitin (30 μg) disk diffusion methods presented 94.4% and 100% sensitivity, respectively, and 98.8% specifi city. The screening test showed 100% sensitivity and 98.8% specificity. All isolates produced β-lactamase and one of these strains was considered to be a hyperproducer. Conclusions: The 30 μg cefoxitin disk diffusion method presented the best result when compared to the 1 μg oxacillin disk. The sensitivity of the agar screening test was similar to that of the cefoxitin disk diffusion method and higher than that of the oxacillin disk diffusion method. We observed variations in the percentage of oxacillin-resistant isolates during the study period, with a decline over the last years which might be related to improved nosocomial infection control and the rational use of antibiotics. [ABSTRACT FROM AUTHOR]

During 2003 and 2004 an estimated 2000 pregnant women and 31 000 nonpregnant women aged 15 to 44 reported using heroin. The majority of those newborns exposed in utero to opioids will develop symptoms of neonatal abstinence syndrome (NAS). Standardized guidelines for the evaluation and management of opiate-exposed newborns are lacking. The objective of this study was to document variations in the evaluation and management of opiate-exposed newborns among Maryland hospitals using a 13-item phone survey. Twenty-seven (82%) of the hospitals completed the survey. Staff at every hospital reported that they delivered opiate-exposed infants, however only 52% reported using a standardized evaluation and treatment protocol for this population consisting of guidelines for maternal toxicology screening, length-of-stay criteria and a monitoring tool for drug-exposed infants, infant supportive care techniques, and pharmacologic treatment guidelines. Significant variability exists in the evaluation and management of opiate-exposed newborns in Maryland. Validated, evidence-based guidelines are needed to standardize the care of these vulnerable newborns across all hospital settings. [ABSTRACT FROM AUTHOR]

A case of an infant who had morphine exposure during and following pregnancy while her mother was treated with intrathecal (IT) morphine is presented along with a review of the relevant literature. Successful maternal pain management was achieved during pregnancy and while breastfeeding. Minimal maternal serum and breast milk levels in the first 7 postpartum weeks were found. Also, infant sleep and arousal behavior and general development at 2 and 7 months were unremarkable, illustrating the possible safe and efficacious use of IT morphine during and following pregnancy. Further work is required to understand opioid pharmacology during breastfeeding, which will be used to develop an empirical approach to breastfeeding and morphine use. [ABSTRACT FROM PUBLISHER]

Two case reports of breastfeeding mothers on high doses of methadone and a literature review reveal that minimal transmission of methadone into breast milk occurs regardless of the mother's methadone dose. The current American Academy of Pediatrics recommendations that only women in drug treatment programs on less than 20 mg/day of methadone be advised to breastfeed should be reconsidered. [ABSTRACT FROM PUBLISHER]

Background: Paronychia is defined as infection afflicting the eponychial nail folds of the hand or foot. Such infections are rarely reported in the perinatal age group, and not previously described in a neonate younger than 2 weeks. Trauma resulting in inoculation of the nail fold is the most common predisposing factor to paronychia. Oral trauma in the pediatric population from finger sucking predisposes this population to a different set of bacterial pathogens than adults. Contamination can progress to infection and abscess formation within the nail fold with the most prevalent vector in adult infections being Staphylococcus aureus. Comparatively, mixed anaerobic and aerobic infections tend to afflict children with oral soothing habits. Methods: This is a case report will present the rare occurrence of a paronychia in a neonate caused by methicillin-resistant Staphylococcus aureus. Results: The management and treatment strategies for paronychia in this atypical neonatal patient consisted of incision and drainage and antibiotic therapy. Conclusion: Neonates with oral selfsoothing behaviors may be more at risk for developing paronychia of mixed anaerobic and aerobic infections. Initial therapy with broad-spectrum antibiotics amoxicillin/clavulanate or clindamycin is suggested. Incision and drainage in the perinatal setting coupled with antibiotics is curative. [ABSTRACT FROM AUTHOR]

The numbers of women using opioids who become pregnant have captured the attention of media, research, policy, and community. At the same time, there is an ever-growing use of alcohol among women who continue drinking during pregnancy that has received less focus. Although both untreated opioid use disorder and alcohol misuse pose risks for maternal, fetal, and child morbidities, alcohol is the substance with the most significant documentation of harms. As we focus on the opioid epidemic in the United States, it is critical that we do not overlook alcohol use during pregnancy. Both opioid use and alcohol use during pregnancy are important public health challenges and often happen concurrently. Thus, this commentary aims to (1) highlight the historical and current context of opioid and alcohol use during pregnancy; (2) summarize the current knowledge of opioids and alcohol use during pregnancy; and (3) detail future directions in how health care providers can help identify and therapeutically respond to women with concurrent opioid and alcohol use disorder. [ABSTRACT FROM AUTHOR]

Prenatal exposure to substances may influence a child's neurodevelopment and impact on subsequent mental health. In a hospital-based population of school-aged children prenatally exposed to opiates and a number of illicit substances (n = 57), we evaluated mental health symptoms associated with attention deficit/hyperactivity disorder (ADHD) and autism spectrum disorders (ASD) using the Swanson, Nolan, and Pelham Questionnaire, revision IV (SNAP-IV) and the Autism Spectrum Screening Questionnaire (ASSQ) and compared the scores to a reference group which comprised children from the population-based Bergen Child Study (n = 171). Prenatally exposed children had significantly higher SNAP-IV scores associated with ADHD symptoms in both areas of inattention and hyperactivity/impulsivity and also reported a higher ASSQ score related to an increased number of symptoms associated with ASD, compared with the reference group. Of tested predictors of mental health outcomes in the exposed group, the intelligence quotient was a strong predictor of most mental health outcomes, and neonatal abstinence syndrome was a predictor of inattention. In conclusion, prenatally exposed children had more mental health symptoms associated with ADHD and ASD, compared with the reference group. [ABSTRACT FROM AUTHOR]

A letter to the editor is presents which discusses a first case report on the effect of laser acupuncture therapy combined with a basic pharmacological treatment in a neonate with neonatal abstinence syndrome (NAS).