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Objectives. To estimate use of medication for opioid use disorder (MOUD) and prescription opioids in pregnancy among mothers of infants with neonatal opioid withdrawal syndrome (NOWS). Methods. We used linked 2016–2018 North Carolina birth certificate and newborn and maternal Medicaid claims data to identify infants with an NOWS diagnosis and maternal claims for MOUD and prescription opioids in pregnancy (n = 3395). Results. Among mothers of infants with NOWS, 38.6% had a claim for MOUD only, 14.3% had a claim for prescription opioids only, 8.1% had a claim for both MOUD and prescription opioids, and 39.1% did not have a claim for MOUD or prescription opioids in pregnancy. Non-Hispanic Black women were less likely to have a claim for MOUD than non-Hispanic White women. The percentage of infants born full term and normal birth weight was highest among women with MOUD or both MOUD and prescription opioid claims. Conclusions. In the 2016–2018 NC Medicaid population, 60% of mothers of infants with NOWS had MOUD or prescription opioid claims in pregnancy, underscoring the extent to which cases of NOWS may be a result of medically appropriate opioid use in pregnancy.

BACKGROUND: Previous research indicated that diabetes during pregnancy results in a more permeable placenta. Based on this data, we hypothesized that women with maternal diabetes were more likely to have infants who developed neonatal abstinence syndrome (NAS). PURPOSE: The purpose of the study was to examine the association between maternal diabetes and NAS in a cohort of women reporting substance use during pregnancy. METHODS: This study used data from a population-based cohort of all newborns born in 2017 and 2018 (N = 36,974) in the state of West Virginia and restricted the analysis to those infants with intrauterine substance exposure (14%, n = 5188). Multiple logistic regression was performed to analyze the adjusted relationship between maternal diabetes and NAS while controlling for maternal and infant covariates. RESULTS: Just over 28% of women with diabetes had an infant who developed NAS, whereas 34.8% of women without diabetes had an infant who developed NAS. The adjusted odds ratio of infants developing NAS born to women with diabetes was 0.70 (95% confidence interval: 0.51, 0.94) compared with those born to mothers without diabetes after controlling for covariates. Contrary to our hypothesis, the study suggests that maternal diabetes during pregnancy is associated with a decreased risk of an infant developing NAS. IMPLICATIONS FOR PRACTICE: Future research generating from this hypothesis may lead to potential implications for practice for infants born to mothers with substance use during pregnancy and diabetes. IMPLICATIONS FOR RESEARCH: More research should be conducted to investigate the relationship between glucose metabolism and NAS.

Background Infants with neonatal abstinence syndrome (NAS) are at an increased risk for diaper dermatitis, which can cause skin breakdown and lead to significant pain and potential infection exposure. Skin care protocols in the neonatal intensive care unit (NICU) setting seldom specifically address the needs of this at-risk population, leading to inconsistent skin care management. Purpose The goal was to support a decrease in the rate of diaper dermatitis for infants with NAS by designing and implementing an evidence-based skin care protocol. Methods A retrospective medical record review was used to examine outcomes of 25 infants preintervention and 8 infants postintervention. The skin care protocol was a bundle of 5 evidence-based interventions: (1) a specific diaper dermatitis assessment tool; (2) frequent diaper changes with superabsorbent diapers; (3) application of petroleum jelly and alcohol-free wipes; (4) infant bathing in pH neutral soap; and (5) application of zinc oxide barrier cream for erythema. Results There was an overall 80.5% decrease in diaper dermatitis from pre- to postimplementation (P ≤ .01) as noted when comparing positive cases of diaper dermatitis with negative cases from pre- to postintervention. Implications for practice Expanding the skin care protocol to all neonates in the NICU and nursery could aid in maintaining skin integrity and decreasing diaper dermatitis in the NICU. More research is needed following this study for the data to be generalizable to other NICUs. This study offers key takeaways including using a specific diaper dermatitis assessment tool and consistently using the bundle of interventions.Video Abstract Available at:https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=47.

Background Validation studies estimating the positive predictive value (PPV) of neonatal abstinence syndrome (NAS) have consistently suggested overreporting in hospital discharge records. However, few studies estimate the negative predictive value (NPV). Even slightly imperfect NPVs have the potential to bias estimated prevalences of rare outcomes like NAS. Given the challenges in estimating NPV, our objective was to evaluate whether the PPV was sufficient to understand the influence of NAS misclassification bias on conclusions of the NAS prevalence in surveillance research. Methods We used hospital discharge data from the 2016 New Jersey State Inpatient Databases, Healthcare Cost and Utilization Project. We adjusted surveillance data for misclassification using quantitative bias analysis models to estimate the expected NAS prevalence under a range of PPV and NPV bias scenarios. Results The 2016 observed NAS prevalence was 0.61%. The misclassification-adjusted prevalence estimates ranged from 0.31-0.91%. When PPV was assumed to be ≥90%, the misclassification-adjusted prevalence was typically greater than the observed prevalence but the reverse was true for PPV≤70%. Under PPV 80%, the misclassification-adjusted prevalence was less than the observed prevalence for NPV>99.9% but flipped for NPV Conclusions When we varied the NPV below 100%, our results suggested that the direction of bias (over-or underestimation) was dependent on the PPV, and sometimes dependent on the NPV. However, NPV was important for understanding the magnitude of bias. This study serves as an example of how quantitative bias analysis methods can be applied in NAS surveillance to supplement existing validation data when NPV estimates are unavailable.

ObjectiveTo test the hypothesis that cerebral blood flow (CBF) assessed with arterial spin labelling (ASL) MRI is increased and standardised neurological examination is altered in infants with neonatal opioid withdrawal syndrome (NOWS) compared with those without.DesignProspective cohort study.SettingLevel IV neonatal intensive care unit and outpatient primary care centre.ParticipantsInfants with NOWS receiving pharmacological treatment and unexposed controls matched for gestational age at birth and post-menstrual age at MRI.Main outcomesCBF assessed by ASL on non-sedated 3-Tesla MRI and standardised Hammersmith Neonatal Neurological Examination (HNNE) within 14 days of birth.ResultsThirty infants with NOWS and 31 control infants were enrolled and included in the final analysis. Global CBF across the brain was higher in the NOWS group compared with controls (14.2 mL/100 g/min±5.5 vs 10.7 mL/100 g/min±4.3, mean±SD, Cohen’s d=0.72). HNNE total optimality score was lower in the NOWS group compared with controls (25.9±3.6 vs 28.4±2.4, mean±SD, Cohen’s d=0.81). A penalised logistic regression model including both CBF and HNNE items discriminated best between the two groups.ConclusionsIncreased cerebral perfusion and neurological examination abnormalities characterise infants with NOWS compared with those without intrauterine drug exposure and suggest prenatal substance exposure affects fetal brain development. Identifying neurological and neuroimaging characteristics of infants with NOWS can contribute to understanding mechanisms underlying later outcomes and to designing potential new treatments.

Purpose The purpose of this study was to examine patterns of health and developmental outcomes in children with prenatal opioid exposure (POE) and neonatal abstinence syndrome (NAS) compared to children without exposure during the first three years of life. Design and methods This was a secondary data analysis of the Maternal and Infant Data Hub (MIDH), a de-identified dataset originating from the Midwest region of the United States, consisting of newborn billing records and corresponding maternal and child electronic medical records. For these analyses, the repository included data on more than 20,000 children born between 2013 and 2019. Diagnoses were identified with International Classification of Diseases, ninth and tenth Revision, Clinical Modification codes (ICD-9/10-CM). Firth logistic regression was used to assess whether incidence of each diagnosis code differed by exposure group. Results Among 20,389 children in the dataset, 13,173 were unexposed; 455 were POE, and 199 were POE + NAS. There were significant differences in frequency of diagnoses between groups, specifically regarding growth and development, infection, mental health, musculoskeletal, neonatal, sensory, and social issues. When comparing exposed groups, children with POE + NAS experienced more negative health outcomes than children with only POE across all years. Conclusions This study implicates POE as a significant variable associated with many health and developmental outcomes of children during the first three years of life. Practice implications It is crucial to understand and identify health risks observed more frequently in exposed children during such a critical period of growth and brain development.

Aim This concept analysis aimed to offer insight into how opioid exposure affects the quality and construction of the maternal-infant bond. Background Maternal-infant bonding can be influenced by maternal opioid use disorder and the neonatal intensive care unit environment. Many interventions for mothers with opioid use disorder focus on enhancing parental skills, but often the emotional and relational features of the maternal-infant bond have been overlooked. Data source Literature from Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, PubMed, and PsycINFO published from January 2011 to June 2021 using "attachment theory," "mother-infant attachment," "maternal-infant bonding," "neonatal opioid withdrawal syndrome," and "neonatal abstinence syndrome" as key terms. Review methods Rodgers' method of concept analysis was used to determine the antecedents, attributes, and consequences of maternal-infant bonding. Results The key attributes of bonding for the opioid-exposed mother-infant dyad are engaged mothering, recognition of risk, affection, and respectful maternity care. The antecedents are closeness, selflessness, and purposeful touch. The consequences are sobriety, custody, love, and security.

Opioid use in the perinatal period has escalated rapidly, with potentially devastating outcomes for perinatal persons and infants. Substance use treatment is effective and has the potential to greatly improve clinical outcomes; however, characteristics of care received from providers including nurses have been described as a barrier to treatment. Our purpose was to describe supportive perinatal care experiences of persons with opioid use disorder. A qualitative descriptive study design was used to examine experiences of 11 postpartum persons (ages 22-36 years) in medication-assisted treatment for opioid use disorder at an academic medical center in the southern region of the United States. Participants were interviewed about experiences with perinatal and neonatal care during the child's hospitalization for neonatal abstinence syndrome surveillance and/or treatment. Four themes of supportive care experiences emerged: informing, relating, accepting, and holistic supporting. Participants reported a range of positive and negative perinatal care experiences, with examples and counterexamples provided. This fuller understanding of perceptions and lived experiences of care can inform practice changes and educational/training priorities. Future research is needed to facilitate development of comprehensive care models geared to address perinatal care needs of persons with opioid use disorder.

Background Pregnancy and the delivery of an infant mark a unique time of engagement in healthcare for women in treatment for opioid use disorder (OUD). The American College of Obstetrics and Gynecology calls for a comprehensive approach to perinatal healthcare delivery for pregnant women with OUD in order to facilitate improved health outcomes and increase patient-provider collaboration. Yet, there is little knowledge regarding the perceptions of women with OUD regarding the current delivery of healthcare which could inform a personalized, tailored approach to perinatal healthcare delivery. Methods Four focus groups consisting of 22 women with OUD were conducted, transcribed, and analysed using qualitative thematic analysis methodology. Results Women reported an overall lack of preparation for the birth and neonatal healthcare experiences and identified opportunities for greater support by the healthcare team. Women emphasized the desire for evidence-based preparation from trusted sources about delivery, neonatal abstinence syndrome, breastfeeding, and how their medications affect their pregnancy and baby. Women reported receiving a varied amount of support from healthcare providers in their transition to motherhood, but women predominantly reported receiving emotional and informational support from their mothers and partners. Conclusions The knowledge obtained in this study points to gaps in perinatal healthcare delivery for women with OUD. Improving the delivery of perinatal healthcare may contribute to increased engagement by women with OUD, and ultimately improve outcomes for a vulnerable population.

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.

The prevalence of opioid use disorder (OUD) among pregnant women is increasing. Research consistently demonstrates the efficacy of medications for OUD (MOUD); however, researchers have called for additional studies evaluating the safety of MOUD during pregnancy, particularly the relative safety of two commonly used MOUD medications-methadone and buprenorphine. This study aimed to evaluate the consequences of MOUD exposure during pregnancy on risk for neonatal abstinence syndrome (NAS).In a clinical sample of infants born to women with OUD, we evaluated the risk of NAS among those exposed to (i) methadone and (ii) buprenorphine compared with those unexposed to MOUD, as well as the risk of NAS among those exposed to (i) methadone compared with those exposed to (ii) buprenorphine.Compared with buprenorphine-exposed infants (n = 37), methadone-exposed infants (n = 27) were at increased risk for NAS (odds ratio [OR] = 4.67, 95% confidence interval [CI]: 1.03, 21.17). Compared with unexposed infants (n = 43), buprenorphine-exposed infants were at decreased risk for NAS (OR = 0.45, 95% CI: 0.14, 1.39) and methadone-exposed infants were at increased risk for NAS (OR = 2.64, 95% CI: 0.79, 8.76), though these associations were not statistically significant.Our study suggests that when methadone and buprenorphine are equally appropriate options for the treatment of OUD in pregnant women, buprenorphine may add the additional benefit of reduced risk of newborn NAS.Medications for opioid use disorder (MOUD), such as buprenorphine and methadone, are effective in reducing the significant harms associated with untreated opioid use disorder (OUD) in nonpregnant and pregnant adults. While previous research clearly documents that the risks of MOUD in pregnancy are less than the risks of untreated OUD in pregnancy, researchers have called for additional studies evaluating the safety of MOUD during pregnancy, particularly the relative safety of methadone and buprenorphine. In a clinical sample of infants born to women with OUD, we showed that buprenorphine-exposed infants were at significantly reduced risk for neonatal abstinence syndrome compared with methadone-exposed infants. Our study adds to the growing body of evidence supporting the use of buprenorphine over methadone for the treatment of OUD among pregnant women.

Neonates born to mothers taking opioids during pregnancy are at risk for neonatal opioid withdrawal syndrome (NOWS), for which there is no recognized standard approach to care. Nonpharmacologic treatment is typically used as a first-line approach for management, and pharmacologic treatment is added when clinical signs are not responding to nonpharmacologic measures alone. Although morphine and methadone are the most commonly used pharmacotherapies for NOWS, buprenorphine has emerged as a treatment option based on its pharmacologic profile and results from initial single site clinical trials. The objective of this report is to provide an overview of NOWS including a summary of ongoing work in the field and to review the state of the science, knowledge gaps, and practical considerations specific to the use of buprenorphine for the treatment of NOWS as discussed by a panel of experts during a virtual workshop hosted by the National Institutes of Health.

BACKGROUND: Postpartum is a highly vulnerable time for women with opioid use disorder (OUD). Our primary objective was to identify patient and provider reported aspects of the pregnancy to postpartum transition that impact recovery progress for postpartum women receiving medication for opioid use disorder (MOUD). METHODS: This qualitative study consisted of semi-structured interviews with postpartum women in OUD treatment (n = 12) and providers (n = 9) at an outpatient addiction clinic. Interviews were transcribed and analyzed using an editing style approach to report themes and quotes. RESULTS: Patients and providers identified different themes that both promote and challenge recovery during the postpartum transition. These comprised of clinical factors, including MOUD, neonatal opioid withdrawal syndrome (NOWS) and pain associated with labor and delivery as well as psychosocial factors, such as role of a support system, mental health aspects of anxiety and depression causing mood changes, stigma and mistrust among healthcare providers and child welfare. CONCLUSIONS: Patients receiving MOUD and their providers identified multiple aspects unique to the postpartum transition that substantially strengthen and/or oppose OUD recovery. These aspects impacting recovery include factors specific to the receipt of MOUD treatment and those not specific to MOUD, yet tied to the postpartum state. Overall, these findings provide insight into areas for future research focused on identifying opportunities to promote recovery-oriented care for families affected by OUD.

Purpose To improve outcomes of infants with neonatal abstinence syndrome (NAS) by implementing an evidence-based approach to care. Methods An interdisciplinary team developed and implemented an educational module about the elements and principles of trauma-informed care (TIC) and standardized education on NAS for mothers with substance use disorder (SUD). The team collaborated with community behavioral health professionals to secure the services of a certified recovery specialist. Primary outcome measures of average length of stay (LOS) and admissions to special care nursery (SCN) for NAS infants were analyzed. Results Following health care team education on TIC and implementation of the standardized NAS brochure, average LOS decreased significantly from 6.5 to 5.1 days from baseline period (January-December 2019) to the implementation period (February-June 2020; p = 0.03). There was no difference in SCN admission from the baseline period (February-June 2019) to the implementation period (February-June 2020). Referrals to certified recovery specialists did not change. Clinical implications Education on the impact of trauma on new mothers with SUD can promote collaboration between them and the neonatal team. Standardizing education for new mothers of infants with NAS can help to engage families of infants with NAS and improve clinical outcomes.

Background The opioid epidemic in the United States continues to threaten public health. As a result of this crisis, neonatal opioid withdrawal syndrome (NOWS) has risen exponentially and requires a multitude of non-pharmacologic treatments to ensure healthy neonatal outcomes. Methods This feasibility study implemented an acupressure protocol as informed by the Near-Term Infant (NTI) conceptual framework for the treatment of NOWS. Aims of this study were to assess provider training, effective integration of acupressure within the standard of care, and acceptance of this treatment by mothers and healthcare providers. Results With maternal consent, a total of 12 participants were enrolled and underwent auricular acupressure. Nurse Practitioners were credentialed (75%) and effectively administered neonatal acupressure (100%) in accordance with the study protocol. Mothers were very satisfied with acupressure for the treatment of NOWS (Client Satisfaction Questionaire-8 mean scores 3.8–4.0 of a possible 4.0), and the majority of healthcare providers were supportive (66%, mean scores 3.6 to 4.0 out of possible 5). Conclusions Auricular acupressure was successfully implemented within the standard of care for NOWS. Future studies should incorporate outlined suggestions and include qualitative measures of acceptance as well as randomized controlled trials to evaluate efficacy.

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.

Background: Little is known about rates of substance use disorder (SUD) treatment for women in dyads affected by substance use in the immediate postpartum period. This study's objectives were to (1) identify characteristics of mothers of infants with neonatal abstinence syndrome (NAS) and/or prenatal substance exposure (PSE) who did or did not receive SUD treatment in the first 60 days postpartum and (2) describe timing of treatment receipt. Methods: This descriptive study examined linked mother–infant dyads using Medicaid data from Louisiana, Massachusetts, and Wisconsin for 2006–2009. Dyads were included if the infant had NAS and/or PSE. Descriptive statistics on sociodemographic characteristics, prenatal SUD, mental health conditions, Medicaid enrollment, and health care utilization were reported for women who did and did not receive SUD treatment in the first 60 days postpartum. The distribution of each variable was compared using chi-square tests. The timing of first postpartum treatment in weeks since delivery was examined. Results: Among Medicaid-insured women whose infants had in utero substance exposure, 15% received any postpartum SUD treatment. Fewer than half were diagnosed with SUD prenatally. Of those who received postpartum SUD treatment, 68% had received prenatal treatment. No association was observed between postpartum SUD treatment receipt and months of Medicaid enrollment in the year before delivery, prenatal visits, or postpartum visit attendance. Conclusions: Most women who likely need postpartum SUD treatment did not receive it and multipronged solutions are needed. These findings provide a useful baseline for evaluations of policies aimed at improving maternal health.

Untreated opioid misuse in pregnancy is associated with adverse outcomes. Limited information is available on maternal and perinatal outcomes in subsequent pregnancies for individuals initiated on medication for opioid use disorder (MOUD) in a prior pregnancy.Evaluate maternal and neonatal outcomes in subsequent pregnancies for individuals initiated on MOUD in prior pregnancy.Historical cohort study including individuals with opioid use disorder with ≥2 pregnancies between 2013 and 2020, received care in our colocated multidisciplinary clinic for1 pregnancy, and delivered at our institution. Primary outcome was rate of preconception MOUD. Secondary outcomes included rate of neonatal opioid withdrawal syndrome requiring pharmacologic treatment and length of hospital stay.Forty-two individuals with opioid use disorder in their index pregnancies (n = 42) and 46 subsequent pregnancies were identified. Individuals were more likely to receive long-acting reversible contraception in subsequent pregnancies (35% vs 14%, P = 0.04). No differences in tobacco use, gestational age at initiation of prenatal care or delivery was noted. Individuals in their subsequent pregnancies were 6 times more likely to be on MOUD preconception (78% vs 36%; OR, 6.48; [95% CI, 2.52-16.64]) and 67% less likely to have positive illicit urine drug screen upon initiation of care (36% vs 64%; OR, 0.33; 95% [CI, 0.14-0.78]). Neonates had similar rates of neonatal abstinence withdrawal syndrome requiring pharmacological treatment, positive illicit toxicology results, and neonatal length of stay.Participation in multidisciplinary obstetric and opioid use disorder program increases rate of MOUD in subsequent pregnancy with decrease in illicit drug use.

Objective: It is known that the use of alcohol, illicit drugs and psychoactive substances during pregnancy is significantly associated with maternal, fetal and neonatal morbidities. We planned to investigate the characteristics of babies born to mothers who use illicit substances.Method: Babies born to mothers using illicit drugs and healthy babies born between September 2019 and December 2021 were included in the study. Demographic, clinical and laboratory data of the patients and modified Finnegan scores were recorded retrospectively from the file data.Results: A total of 24 infants, 11 infants of drug-using mothers and 13 healthy infants in the control group, were included in the study. Ages of mothers, gestational weeks, birth weights, and APGAR scores at 1st and 5th minutes of babies born to mothers who used substance were found to be statistically lower than healthy babies. The rates of leukopenia and neutropenia were found to be significantly higher in patients with a modified Finnegan score ≥8 and in need of morphine (n:4/11) compared to patients without morphine need (n:7/11).Conclusion: There is a need for detailed studies on the prevention of illicit substance use as a current health problem, the development of policies on early detection and follow-up, and the search for new biomarkers for the early detection of infants followed for neonatal withdrawal syndrome., Amaç: Gebelik döneminde alkol, yasadışı uyuşturucu ve psikoaktif madde kullanımının önemli ölçüde maternal, fetal ve neonatal morbiditelerle ilişkili olduğu bilinmektedir. Yasadışı madde kullanan anneden doğan bebeklerin özelliklerini araştırmayı planladık.Yöntem: Çalışmaya Eylül 2019 ve Aralık 2021 tarihleri arasında doğan yasadışı uyuşturucu madde kullanan anne bebekleri ve kontrol grubu olarak sağlıklı bebekler dahil edildi. Hastaların demografik, klinik ve laboratuvar verileri ile modifiye Finnegan skorları retrospektif olarak dosya verilerinden kaydedildi.Bulgular: Çalışmaya uyuşturucu madde kullanan anne bebeği 11 ve kontrol grubuna 13 sağlıklı bebek olmak üzere toplam 24 bebek dahil edildi. Madde kullanan annelerin yaşları, gebelik haftaları, doğum ağırlıkları, 1. ve 5. dakikada APGAR skorları sağlıklı bebeklerden istatistiksel olarak daha düşük bulundu. Modifiye Finnegan skoru ≥8 olup morfin ihtiyacı olan (n:4/11) hastalarda lökopeni ve nötropeni oranı morfin ihtiyacı olmayan (n:7/11) hastalara göre anlamlı olarak yüksek bulundu.Sonuç: Güncel sağlık problemi olarak yasadışı madde kullanımının önlenmesi, erken tespit ve izlemi konusunda politikaların geliştirilmesi ve neonatal yoksunluk sendromu açısından izlenen bebeklerin erken tespiti için yeni biomarkerların araştırılması konusunda detaylı çalışmalara ihtiyaç vardır.

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 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.

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.

Opioid abuse during pregnancy can result in Neonatal Opioid Withdrawal Syndrome (NOWS). We investigated genome-wide methylation analyses of 96 placental tissue samples, including 32 prenatally opioid-exposed infants with NOWS who needed therapy (+Opioids/+NOWS), 32 prenatally opioid-exposed infants with NOWS who did not require treatment (+Opioids/-NOWS), and 32 prenatally unexposed controls (-Opioids/-NOWS, control). Statistics, bioinformatics , Artificial Intelligence (AI), including Deep Learning (DL), and Ingenuity Pathway Analyses (IPA) were performed. We identified 17 dysregulated pathways thought to be important in the pathophysiology of NOWS and reported accurate AI prediction of NOWS diagnoses. The DL had an AUC (95% CI) =0.98 (0.95–1.0) with a sensitivity and specificity of 100% for distinguishing NOWS from the +Opioids/-NOWS group and AUCs (95% CI) =1.00 (1.0–1.0) with a sensitivity and specificity of 100% for distinguishing NOWS versus control and + Opioids/-NOWS group versus controls. This study provides strong evidence of methylation dysregulation of placental tissue in NOWS development.

OBJECTIVES: The Modified Finnegan Neonatal Abstinence Scoring System (M-FNASS) and the newer Eat, Sleep, and Console (ESC) model guide the clinical management of neonatal opioid withdrawal syndrome (NOWS). In this study, we evaluate how the M-FNASS and ESC model directly compare in inpatient practice. We hypothesized that ESC scores would correlate with M-FNASS scores, whereas ESC management would reduce health care use for infants with NOWS. METHODS: In this retrospective cohort study, we compared management of infants with NOWS admitted to nursery settings. Epoch 1 was managed by using an M-FNASS algorithm. Epoch 2 was scored simultaneously with the M-FNASS and ESC model and managed by using the ESC approach. In the statistical analysis, we compared M-FNASS and ESC scores and outcomes between epochs. RESULTS: A total of 158 infants provided 2101 scoring instances for analysis. Demographic characteristics were similar between epochs. ESC scores significantly correlated with overall M-FNASS scores and specific M-FNASS domains. Receiver operating characteristic (ROC) curve analysis revealed that an ESC score containing at least 1 “no” was best predicted by an M-FNASS cutoff value of 7.5 (sensitivity 0.84; specificity 0.70; area under the curve = 0.842). Length of stay (median 9.5 vs 5 days; P = .0002) and initiation (53% vs. 33%; P = .018) and duration of pharmacologic treatment (median 11 vs 7 days; P = .0042), as well as length of stay for infants who were pharmacologically treated (median 15 vs 10 days; P = .0002), were significantly reduced with ESC-based management after adjustment for covariates. CONCLUSIONS: The ESC approach meaningfully correlates with the M-FNASS to detect NOWS. Management with the ESC approach continues to be associated with reduced health care use when compared with an M-FNASS approach, implying that the ESC approach may facilitate higher-value inpatient care.

BACKGROUND: At our institution, the treatment of infants with neonatal abstinence syndrome (NAS) is guided by a function-based assessment called the Eat, Sleep, Console (ESC) approach. Infants room in with their parent(s) on the inpatient units, and most infants are treated exclusively with nonpharmacologic interventions. The experience of parents of infants with NAS treated with the ESC approach is unknown. METHODS: We chose a deductive, hypothesis-driven approach to perform a content analysis of transcripts from in-depth, semistructured interviews of parents of infants with NAS in our institution. Responses were audiotaped, transcribed, and reviewed by at least 3 members of the research team. RESULTS: We interviewed 18 parents of infants with NAS. Most participants were ≥30 years, were white, and had a high school or equivalent level of education. Four major themes emerged: (1) parents were supportive of fewer interventions and normalizing of newborn care in the ESC approach; (2) parents felt encouraged to lead their infant’s NAS care; (3) parents perceived gaps in communication about what to expect in the hospital immediately after delivery and during their infant’s hospital stay; and (4) parents experienced feelings of guilt, fear, and stress and expressed the need for increased support. CONCLUSIONS: Parents in our study had an overall positive experience with the ESC approach. This engagement probably contributes to the success of the ESC approach in our institution. Future opportunities include better preparation of expectant mothers and continued emotional support after delivery.

Background/significance Intrauterine opioid drug exposure is associated with an increased risk of preterm birth. Preterm infants may not exhibit the same withdrawal symptoms as term infants diagnosed with neonatal abstinence syndrome (NAS). There are no current standards for how to screen, assess, or treat NAS in preterm infants. Purpose This study explored the current state of practice for preterm infants born at less than 34 weeks of gestational age exposed to intrauterine opioids. Methods This was a descriptive cross-sectional study of NAS practice in preterm infants born at less than 34 weeks of gestational age in neonatal intensive care units (NICUs) in the United States and Canada. The study was conducted May through September 2018. All respondents cared for preterm infants born at less than 34 weeks of gestational age exposed to intrauterine drugs. Results There were 70 respondents representing 67 hospitals in the United States and 1 in Canada. Level III NICUs represented 69% of respondents. Ninety-three percent reported neonatal triggers for further evaluation. Review of maternal history and maternal urine testing was the most consistent practice across NICUs. A modified Finnegan scoring tool was used for both preterm and term infants. Morphine was reported as the most common first-line drug used for treatment. Implications for practice Great variability in NAS practice for preterm infants born at less than 34 weeks of gestational age across the multiple NICUs supports the need for a validated preterm infant assessment tool and development of appropriate treatment strategies. Implications for research Future research describing the NAS symptomatology of preterm infants born at less than 34 weeks of gestational age exposed to intrauterine opioids is warranted.

Opioids are potent analgesics used to manage pain in both young and old, but the increased use in the pregnant population has significant individual and societal implications. Infants dependent on opioids, either through maternal or iatrogenic exposure, undergo neonatal opioid withdrawal syndrome (NOWS), where they may experience withdrawal symptoms ranging from mild to severe. We present a detailed and original review of NOWS caused by maternal opioid exposure (mNOWS) and iatrogenic opioid intake (iNOWS). While these two entities have been assessed entirely separately, recognition and treatment of the clinical manifestations of NOWS overlap. Neonatal risk factors such as age, genetic predisposition, drug type, and clinical factors like type of opioid, cumulative dose of opioid exposure, and disease status affect the incidence of both mNOWS and iNOWS, as well as their severity. Recognition of withdrawal is dependent on clinical assessment of symptoms, and the use of clinical assessment tools designed to determine the need for pharmacotherapy. Treatment of NOWS relies on a combination of non-pharmacological therapies and pharmacological options. Long-term consequences of opioids and NOWS continue to generate controversy, with some evidence of anatomic brain changes, but conflicting animal and human clinical evidence of significant cognitive or behavioral impacts on school-age children. We highlight the current knowledge on clinically relevant recognition, treatment, and consequences of NOWS, and identify new advances in clinical management of the neonate. This review brings a unique clinical perspective and critically analyzes gaps between the clinical problem and our preclinical understanding of NOWS.

Newborns with neonatal abstinence syndrome (NAS) display symptoms related to neurologic excitability and autonomic dysfunction that result in increased metabolic demands. These infants also exhibit feeding difficulties and/or hyperphagia. Because the effects of these symptoms and behaviors on growth are unknown, we sought to measure serial body composition measurements over the first 4 months in infants with NAS requiring pharmacologic treatment using air displacement plethysmography. Fourteen infants of singleton birth with appropriate-for-gestational-age (AGA) weight and a gestational age of ≥35 weeks and N = 5) requiring multidrug therapy for symptom control had lower mean fat percent (−1.2%, CI: −5.2–2.1), fat mass (−60 g, CI: −25–13), and fat-free mass (−270 g, CI: −610–80) across time compared to infants requiring monotherapy. We are the first to report how body composition measures change over time in a small group of patients with NAS. Infants with NAS were smaller and leaner in the first several weeks compared to previously reported body composition measurements in term infants, but grew similarly to their healthy counterparts by 16 weeks. Infants with more severe NAS may be at risk for abnormalities in longer term growth.

ObjectiveTo determine the incidence of neonatal abstinence syndrome (NAS) across neonatal units, explore healthcare utilisation and estimate the direct cost to the NHS.DesignPopulation cohort study.SettingNHS neonatal units, using data held in the National Neonatal Research Database.ParticipantsInfants born between 2012 and 2017, admitted to a neonatal unit in England, receiving a diagnosis of NAS (n=6411).Main outcome measuresIncidence, direct annual cost of care (£, 2016–2017 prices), duration of neonatal unit stay (discharge HR), predicted additional cost of care, and odds of receiving pharmacotherapy.ResultsOf 524 334 infants admitted during the study period, 6411 had NAS. The incidence (1.6/1000 live births) increased between 2012 and 2017 (β=0.07, 95% CI (0 to 0.14)) accounting for 12/1000 admissions and 23/1000 cot days nationally. The direct cost of care was £62 646 661 over the study period. Almost half of infants received pharmacotherapy (n=2631; 49%) and their time-to-discharge was significantly longer (median 18.2 vs 5.1 days; adjusted HR (aHR) 0.16, 95% CI (0.15 to 0.17)). Time-to-discharge was longer for formula-fed infants (aHR 0.73 (0.66 to 0.81)) and those discharged to foster care (aHR 0.77 (0.72 to 0.82)). The greatest predictor of additional care costs was receipt of pharmacotherapy (additional mean adjusted cost of £8420 per infant).ConclusionsThis population study highlights the substantial cot usage and economic costs of caring for infants with NAS on neonatal units. A shift in how healthcare systems provide routine care for NAS could benefit infants and families while alleviating the burden on services.

Supplemental Digital Content is available in the text., Background: It is unclear whether confounding accounts for the increased risk of preterm birth and small for gestational age (SGA) birth in opioid analgesic exposed pregnancies. Methods: Using universal coverage health data for Ontario, we assembled a cohort of mother–infant pairs without opioid use disorder (627,172 pregnancies and 509,522 women). We estimated risk ratios (RRs) between opioid analgesics and preterm birth, SGA birth, and stillbirth; neonatal abstinence syndrome was a secondary outcome. We used high-dimensional propensity scores and sensitivity analyses for confounding adjustment. Results: 4% of pairs were exposed, mainly to codeine (2%), morphine (1%), and oxycodone (1%). Compared with unexposed, the adjusted risk of preterm birth was higher with any (1.3, 95% confidence interval [CI] = 1.2, 1.3), first- (RR: 1.2, 95% CI = 1.2, 1.3), and second-trimester (RR: 1.3, 95% CI = 1.2, 1.4) opioid analgesic exposure. Preterm birth risk was higher for first- and second-trimester codeine, morphine, and oxycodone exposure, and for third-trimester morphine. There was a small increase in SGA with first-trimester exposure to any opioid analgesic or to codeine. Exposed pregnancies had an elevated stillbirth risk with any (RR: 1.6, 95% CI = 1.4, 1.8), first- and second-trimester exposure. Few infants had neonatal abstinence syndrome (N = 143); the risk was higher in exposed (RR: 3.6, 95% CI = 2.1, 6.0). In sensitivity analyses of unmeasured confounding, an elevated risk in exposed pregnancies persisted for preterm birth but not SGA. Conclusions: Opioid analgesic-exposed pregnancies had a small increased risk of preterm birth and possibly stillbirth after accounting for confounding by indication and sociodemographic factors.

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.

BACKGROUND Traditional medication-based management of neonatal abstinence syndrome (NAS) results in long hospitalizations. Nonpharmacologic treatment and using the Eat, Sleep, Console (ESC) model of care have been shown to decrease lengths of stay (LOSs). PURPOSE To determine whether using the ESC model of care to treat infants with opioid withdrawal resulted in decreased LOSs and number of infants receiving morphine when compared with traditional medication management. METHODS Retrospective medical review for all patients admitted for NAS 12 months before and 12 months after implementing the ESC model of care. Data collected from electronic health records included demographic data, maternal history, infant LOS, infants receiving morphine, and birth weight/weight on day of life (DOL) 5. Univariate analysis was used to control for demographic data/risk factors. A 2-samples t test was used to compare average LOSs. Chi-square test was used to detect differences in the number of infants receiving morphine. Data were analyzed using SAS 9.4 software. RESULTS LOS decreased from mean of 17.7 days to a mean of 5.9 days (P < .0001). The number of infants receiving morphine decreased from 20 (58.9%) to 1 (2.7%) (P < .0001). No statistically significant difference was noted in the percentage of weight loss on DOL 5. Data showed an increase in breastfeeding rates from 41.18% to 64.86% (P = .0456). IMPLICATIONS FOR PRACTICE The ESC model of care decreased infant LOS and the number of morphine doses administered for opioid withdrawal symptoms. Maternal breastfeeding rates increased. IMPLICATIONS FOR RESEARCH More research is needed to determine long-term neurodevelopmental outcomes of infants managed using ESC principles.

Chronic intrauterine exposure to psychoactive drugs often results in neonatal opioid withdrawal syndrome (NOWS). When nonpharmacologic measures are insufficient in controlling NOWS, morphine, methadone, and buprenorphine are first-line medications commonly used to treat infants with NOWS because of in utero exposure to opioids. Research suggests that buprenorphine may be the leading drug therapy used to treat NOWS when compared with morphine and methadone. Currently, there are no consensus or standardized treatment guidelines for medications prescribed for NOWS. Opioids used to treat NOWS exhibit large interpatient variability in pharmacokinetics (PK) and pharmacodynamic (PD) response in neonates. Organ systems undergo rapid maturation after birth that may alter drug disposition and exposure for any given dose during development. Data regarding the PK and PD of opioids in neonates are sparse. Pharmacometric methods such as physiologically based pharmacokinetic and population pharmacokinetic modeling can be used to explore factors predictive of some of the variability associated with the PK/PD of opioids in newborns. This review discusses the utility of pharmacometric techniques for enhancing precision dosing in infants requiring opioid treatment for NOWS. Applying these approaches may contribute to optimizing the outcome by reducing cumulative drug exposure, mitigating adverse drug effects, and reducing the burden of NOWS in neonates.

The scientific community relies on postmarketing approaches to define the risk of using medications in pregnancy because information available at the time of drug approval is limited. Most studies carried out in pregnancy focus on a single outcome or selected outcomes. However, women must balance the benefit of treatment against all possible adverse effects. We aimed to apply and evaluate a tree-based scan statistic data-mining method (TreeScan; Martin Kulldorff, Harvard Medical School, Boston, Massachusetts) as a safety surveillance approach that allows for simultaneous evaluation of a comprehensive range of adverse pregnancy outcomes, while preserving the overall rate of false-positive alerts. We evaluated TreeScan with a cohort design and adjustment via propensity score techniques, using 2 test cases: 1) opioids and neonatal opioid withdrawal syndrome and 2) valproate and congenital malformations, implemented in pregnancy cohorts nested within the Medicaid Analytic eXtract (January 1, 2000–December 31, 2014) and the IBM MarketScan Research Database (IBM, Armonk, New York) (January 1, 2003–September 30, 2015). In both cases, we identified known safety concerns, with only 1 previously unreported alert at the preset statistical alerting threshold. This evaluation shows the promise of TreeScan-based approaches for systematic drug safety monitoring in pregnancy. A targeted screening approach followed by deeper investigation to refine understanding of potential signals will ensure that pregnant women and their physicians have access to the best available evidence to inform treatment decisions.

Introduction: A clear picture of neonatal withdrawal signs due to in utero selective serotonin reuptake inhibitor (SSRI) exposure and its consequences is still missing. Objective: A systematic review and a meta-analysis were performed to provide an overview of neonatal withdrawal signs following late in utero exposure to SSRIs and to quantify the corresponding risks. Methods: MEDLINE, Web of Science, and Embase were searched from inception to January 2021. The Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines were followed. English-language observational studies reporting on acute postpartum outcomes following late in utero exposure to SSRIs or SSRIs/venlafaxine were evaluated. Results: Of 2,269 citations reviewed, 79 studies were assessed for eligibility; 13 were included in the qualitative analysis of the literature, which allowed us to identify 26 signs. A meta-analysis was run separately for studies on SSRI exposure (n = 3) and those on SSRI/venlafaxine exposure (n = 6). Hypoglycemia was identified as a withdrawal sign based on the SSRI studies. Tremors, hypotonia, tachycardia, rapid breathing, respiratory distress, and hypertonia were identified as withdrawal signs based on the SSRI/venlafaxine studies. Conclusions: The present work provides a framework for the identification of neonatal SSRI withdrawal syndrome. Tapering and discontinuation of antidepressant drugs before and during the early phase of pregnancy are worth attempting to prevent the occurrence of this syndrome.

Background Over the past 2 decades, the prevalence of neonatal abstinence syndrome (NAS) has increased almost 5-fold. Skin-to-skin care (SSC), a method of parent-infant holding, is a recommended nonpharmacologic intervention for managing NAS symptoms. SSC has the potential to reduce withdrawal symptoms while positively influencing parent-infant attachment. Yet, little is known about the SSC experiences of mothers of infants with NAS. Purpose The purpose of this study was to explore the SSC experiences of mothers of infants with NAS, including perceived barriers to SSC in the hospital and following discharge home. Methods A qualitative descriptive design was used to obtain new knowledge regarding the experience of SSC of mothers of infants with NAS. Purposive sampling was used to recruit participants eligible for the study. We conducted semistructured individual interviews with postpartum mothers of infants with NAS. Data were analyzed using thematic analysis. Findings/results Thirteen mothers participated in the study. Four themes emerged from the data analysis: "a little nerve racking"; "she needed me, and I needed her"; dealing with the "hard times"; and "a piece of my puzzle is missing." SSC was described as a conduit for healing and bonding; in addition, several barriers to SSC were reported. Implications for practice and research These findings highlight the inherent benefits of SSC for infants with NAS and demonstrate the unique challenges of these mother-infant dyads. Critical changes in hospital practices are needed to create an environment supportive of SSC for this patient population. In addition, research regarding implementation of interventions to increase SSC usage in this population is warranted.

Purpose Over the last two decades, the number of Americans misusing opioids has reached epidemic levels. With such drastic increases in opioid misuse, audiologists are more likely to have patients with opioid-induced hearing loss or neonatal abstinence syndrome (NAS) than in previous years. More attention is needed on how these increases might influence clinical practice and such a discussion could be useful for audiologists. The goal of this article, therefore, is to summarize what is currently known regarding the relationship between opioid misuse and audiology to help guide hearing health care providers (with a particular focus on opioid-induced hearing loss and NAS). This article (a) summarizes the overlap in opioid misuse and hearing loss populations, (b) describes the evidence linking opioid misuse to hearing loss, (c) discusses clinical implications that opioid-induced hearing loss and NAS have for practicing audiologists, and (d) recommends directions for future audiological research on opioid-induced hearing loss and NAS. Conclusions There is considerable overlap between populations at-risk for hearing loss and opioid misuse. Additionally, compelling evidence exists linking opioid misuse to hearing loss, but the specific causal mechanisms remain unclear, indicating a need for additional research. This article attempts to fill a gap in the audiological literature and has the potential to serve as a guide for hearing health care providers to make more informed clinical decisions regarding patients with opioid-induced hearing loss and NAS. Clinicians may wish to consider the concerns raised in this article before intervening with such concerns, especially in the absence of best practice protocols.

Background The worsening opioid crisis has increased the number of infants exposed to maternal opioids. Standard treatment of newborns exposed to opioids prenatally often requires prolonged hospitalization and separation of the mother-infant dyad. These practices can potentially increase severity of withdrawal symptoms, interrupt breastfeeding, and disturb mother-infant bonding. Use of the Eat, Sleep, Console (ESC) model may ameliorate symptoms, decrease mother-infant separation, and decrease hospital length of stay. Purpose To manage opioid exposed infants in a more holistic manner to decrease neonatal intensive care unit (NICU) admissions, reduce the need for pharmacotherapy, and evaluate response and total length of treatment after a unit protocol change from morphine to buprenorphine. Methods Implemented ESC model, optimized nonpharmacologic bundle, and prescribed buprenorphine therapy instead of morphine as needed for adjunctive therapy. Results Admissions of opioid-exposed infants from the Mother-Baby Unit (MBU) to the NICU decreased by 22%, and the number of infants who required pharmacotherapy was reduced by 50%. The average length of pharmacotherapy fell from 14 to 6.5 days. Implications for practice The successful implementation of the ESC model helped keep the mother-infant dyad together, reduced admissions to the NICU, and lessened the need for pharmacotherapy. The change to buprenorphine further reduced our average length of treatment. Implications for research Investigation of monotherapy with buprenorphine needs to be evaluated as a valid treatment option. The buprenorphine dosing and weaning chart will need to be revised and modified if indicated.

Background The incidence of neonatal abstinence syndrome has increased significantly as a result of the opioid epidemic. A lengthy hospitalization is often required to treat the infant's withdrawal symptoms. A comprehensive understanding of factors that influence nurses' implementation of nonpharmacological interventions for infants with neonatal abstinence syndrome is needed. Purpose To investigate barriers and enablers to nurses' implementation of nonpharmacological interventions for infants with neonatal abstinence syndrome through the lens of the Theoretical Domains Framework, which provides a structure to examine factors that influence healthcare providers' behavior related to the implementation of evidence-based practice and interventions in clinical practice. Methods A convergent parallel mixed-methods study was conducted. Qualitative data were collected using semistructured interviews and quantitative data were collected using a tailored Determinants of Implementation Behavior Questionnaire with neonatal nurses. Findings from the interviews and surveys were merged through joint review to compare and contrast themes. Results Enablers and barriers to nurses' implementation of nonpharmacological interventions included education, experience, ability to implement nonpharmacological interventions, parental participation, stigmatization, lack of managerial/organizational support, staffing ratios, internal and external resources, and stress. Knowledge, Skills, Beliefs About Capabilities, Social/Professional Role and Identity, Organization, and Emotion of the Theoretical Domains Framework aligned with these themes. Implications for practice and research Findings from this study will inform the development of programs to improve nurses' implementation of nonpharmacological interventions and health and utilization outcomes in infants with neonatal abstinence syndrome. Furthermore, future work should focus on the development of programs to improve nurses' implementation of nonpharmacological interventions, with specific strategies aimed to mitigate marginalization of vulnerable patient populations.

The rate of pregnant women with an opioid use disorder has risen drastically in the past 20 years, paralleling that in the general population. Pregnancies associated with opioid use, abuse, or dependence have significantly higher rates of complications, such as neonatal opioid withdrawal syndrome, intrauterine growth restriction, neural tube defects, stillbirth, increased maternal mortality, greater postpartum pain, and longer inpatient stays. Patient education about the risks and benefits of multimodal analgesia and empowering shared decision making may help curb the opioid epidemic. Tailoring pain management to individual needs might be the solution to the problem.

Background The aim of this study was to investigate the association between race and severe neonatal opioid withdrawal syndrome (NOWS) in infants exposed to intrauterine opioids. Methods This is a prospective observational study on intrauterine opioid-exposed term infants. Exposure to opioids was based on maternal disclosure, urine, or umbilical cord drug screening. Severe NOWS was defined based on modified Finnegan scoring and the need for pharmacological intervention. Results One hundred and fifty mother-infant pairs, 60 Black and 90 White with history of opioid exposure during pregnancy, were included. More White than Black infants developed NOWS that required pharmacological treatment, 70 vs. 40%: RR = 1.75 (1.25-2.45). In adjusted analysis, there was no significant association between race and the development of severe NOWS in mothers who attended opioid maintenance treatment program (OMTP). However, in mothers who did not attend OMTP, White race remained a significant factor associated with the development of severe NAS, RR = 1.69 (1.06, 2.69). Conclusions Severe NOWS that required pharmacological intervention was significantly higher in White than in Black infants born to mothers who did not attend OMTP. Larger studies are needed to evaluate the association between social as well as genetic factors and the development of NOWS. Impact There is a significant association between race and development of severe NOWS.

Objectives Many addicted pregnant patients receiving buprenorphine medication-assisted therapy (MAT) wish to discontinue this medication while pregnant. This study was undertaken to determine whether outpatient detoxification from buprenorphine during pregnancy is safe and effective when confirmed with postdetoxification urine drug screens (UDSs). Methods This case series reports the maternal and neonatal outcomes for 21 patients who ended MAT with buprenorphine while pregnant. A retrospective chart review of both maternal and newborn electronic medical records was performed to obtain results. Newborn neonatal abstinence syndrome (NAS) diagnosis, need for morphine, maternal safety and fetal/newborn complications were assessed. Maternal sobriety was documented with UDSs at the time of admission for delivery. Umbilical cord blood also was assessed for substances of abuse. An additional 182 pregnant women who lowered their buprenorphine doses but did not decide to end MAT were assessed via routine quality assurance methods. Results None of the women who stopped buprenorphine during their pregnancy as confirmed by UDSs and umbilical cord sampling delivered neonates who had NAS. Eleven patients ended MAT with medical assistance and 10 ended MAT without medical assistance. No overdoses were reported for the 182 additional pregnant patients who indicated an intention to taper buprenorphine dosage while pregnant but who did not decide to end MAT; the neonatal benefits were obtained without any identified maternal harm. Conclusions The neonates of pregnant women enrolled in an outpatient buprenorphine MAT tapering program who are able to completely stop taking buprenorphine (as documented by negative urinary drug screen) are very unlikely to have NAS. Further research will be important.

Objectives Neonates delivered by women who were taking psychotropic or anticonvulsant drugs during pregnancy are at increased risk of developing neonatal withdrawal syndrome. We investigated the incidence of neonatal withdrawal symptoms and the effects of multiple maternal medications and breastfeeding on neonatal withdrawal symptoms. Study Design This study examined the overall incidence of neonatal withdrawal symptoms in neonates delivered from 2004 to 2016 by women who were taking oral antipsychotics, antidepressants, anxiolytics, sedatives, or anticonvulsant drugs during pregnancy. Moreover, we compared the incidence of neonatal symptoms between mothers taking single drugs and multiple drugs, and between breastfed and formula-fed neonates. We scored the neonates according to the neonatal withdrawal syndrome checklist created by Isobe et al., which is widely used in Japan. Results We examined 131 mothers and their 134 neonates. Withdrawal symptoms were found in 54.5 % of neonates. Symptoms were found in 32.4 % of neonates delivered by mothers taking single drugs and 62.9 % of neonates delivered by mothers taking two or more drugs (p = 0.0019). One or more withdrawal symptoms developed in 46.4 % of breastfed neonates and 66.1 % of formula-fed neonates (p = 0.034). Five infants had a score of 8 or more points on the withdrawal checklist, which is an indication to consider treatment with pharmacotherapy. All five of these neonates were mainly formula-fed, and their mothers were taking two or more drugs. Conclusions The incidence of withdrawal symptoms was high in neonates delivered by women taking psychotropic or anticonvulsant drugs; however, there were few serious cases. The risk increased when a mother was taking multiple drugs. Breastfeeding appeared to protect against withdrawal symptoms.