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Early Weight Loss Percentile Curves and Feeding Practices in Opioid-Exposed Infants (Hosp Pediatr)
Objective: We examined weight loss patterns and feeding practices of infants hospitalized for neonatal opioid withdrawal syndrome (NOWS) managed by the eat, sleep, console approach, which emphasizes nonpharmacologic treatment. Although feeding practices during hospitalization vary widely, weight loss patterns for infants managed under this approach have not yet been described.
Methods: Of 744 infants with NOWS born from 2014 to 2019 at our institution, 330 met inclusion criteria (≥35 weeks' gestation and no NICU transfer). We examined maximum weight loss and created weight loss percentile curves by delivery type using mixed effects quantile modeling with spline effect for hour of life; 95% confidence intervals (CI) were compared to published early weight loss nomograms.
Results: In the cohort, the mean gestational age was 39.2 weeks, mean birth weight was 3.1 kg, and mean length of stay was 6.5 days; 94.6% did not require pharmacologic treatment. Median percent weight loss was significantly more compared to early weight loss nomograms for both vaginally-delivered infants at 48 hours (6.9% [95% CI: 5.8-8.5] vs 2.9%) and cesarean-delivered infants at 48 hours (6.5% [95% CI: 4.1-9.1] vs 3.7%) and 72 hours (7.2% [95%CI 4.7-9.9] vs 3.5%), all P < .001. Overall, 27.9% lost >10% birth weight.
Conclusions: We demonstrate weight loss patterns of infants with NOWS managed by the eat, sleep, console approach at a single center. Infants with NOWS lose significantly more weight than nonopioid exposed infants and are at increased risk of morbidity and health care use. Studies to address optimal feeding methods in these infants are warranted.
Establishing evidence-based pharmacologic treatments for neonatal abstinence syndrome: A retrospective case study - This NAS case study elucidates key factors that contributed to successful research and translation of findings, which may be adaptable to other research contexts. This case also highlights the impact of aligning research with areas of societal interest; the power of connecting clinical care, research, and advocacy to bolster one another; and the critical roles that interdisciplinary teamwork and broad stakeholder collaboration play in overcoming obstacles to research translation.
Characteristics of Prescription Opioid Analgesics in Pregnancy and Risk of Neonatal Opioid Withdrawal Syndrome in Newborns -
Question: Does risk of neonatal opioid withdrawal syndrome (NOWS) after in utero exposure to prescription opioids vary across commonly prescribed types of opioids?
Findings: In this cohort study of 48 202 opioid-exposed pregnancies with liveborn neonates, strong agonists were associated with a higher risk of NOWS compared with weak agonists, and long half-life opioids were associated with an increased risk compared with short half-life products. These associations were independent of morphine milligram equivalents.
Meaning: The study suggests that knowing the varying opioid-specific risk of NOWS associated with in utero exposure may help prescribers select
opioids for pain management in late stages of pregnancy.
Delivery timing for the opioid exposed infant (Am J Obstet Gynecol MFM)
Background: The prevalence of opioid use disorder and medication assisted treatment in pregnancy is increasing. Compared to term infants, preterm infants have a lower incidence of neonatal opioid withdrawal syndrome (NOWS). It is unknown whether early term delivery, compared to full or late term, decreases the risk of NOWS.
Objective: To compare neonatal outcomes among opioid-exposed infants born in the early, full and late-term periods.
Study design: Retrospective cohort of opioid-exposed pregnancies delivering at a single center from 2010-2017 at ≥37weeks gestation. Participants with multiple gestations or fetal anomalies were excluded. Maternal opioid exposure was defined as prescription (including medication assisted treatment) or non-prescription opioids or a positive urine drug screen in pregnancy for opiates. The primary outcome was a neonatal composite of respiratory distress syndrome, neonatal sepsis, neonatal seizures, hypoxic ischemic encephalopathy, jaundice requiring treatment, five-minute Apgar<5, neonatal intensive care unit admission, NOWS or neonatal death. Secondary outcomes included individual components of the primary outcome, birthweight, need for and length of NOWS treatment, length of hospital admission and maximum Finnegan scores. Early (370 - <39), full (390 - <41) and late (410 - <42weeks) term groups were defined by the American College of Obstetrics and Gynecology.
Results: Of 399 infants, 136 (34.1%), 229 (57.4%) and 34 (8.5%) were born in the early, full and late term periods. Two hundred and seventy patients (67.7%) received medication assisted treatment for opioid use disorder and baseline characteristics were similar in all groups except for history of intranasal heroin use, positive urine toxicology screen for heroin or any opiates and delivery indication (p<0.05). The primary composite outcome occurred in 313 (78.4%) neonates and 296 (74.2%) neonates had NOWS. More than half (219 [54.9%]) of opioid exposed neonates were admitted to the neonatal intensive care unit and 160 (40.1%) required pharmacologic NOWS treatment for a mean duration of almost three weeks (19.0 ± 16.1 days). There were no significant differences in the primary composite outcome, incidence of NOWS, or other secondary outcomes (except birthweight) between neonates born in the early, full or late term periods.
Conclusion: Although neonatal morbidity was frequent among opioid-exposed neonates, the incidence and severity of NOWS or other neonatal outcomes were not different between neonates delivered in the early, full and late term periods, suggesting that opioid-exposed infants may not benefit from early term delivery.
Outcomes in Subsequent Pregnancies of Individuals With Opioid Use Disorder Treated in Multidisciplinary Clinic in Prior Pregnancy (J Addict Med)
Background: 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.
Objective: Evaluate maternal and neonatal outcomes in subsequent pregnancies for individuals initiated on MOUD in prior pregnancy.
Methods: Historical cohort study including individuals with opioid use disorder with ≥2 pregnancies between 2013 and 2020, received care in our colocated multidisciplinary clinic for >1 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.
Results: 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.
Conclusions: Participation in multidisciplinary obstetric and opioid use disorder program increases rate of MOUD in subsequent pregnancy with decrease in illicit drug use.
Breastfeeding Experiences in Women from Ten States Reporting Opioid Use Before or During Pregnancy: PRAMS, Phase 8
Results: Among the overall sample, 939 participants reported opioid exposure before or during pregnancy. We found no significant difference in breastfeeding attempt. Breastfeeding for at least 6, 10, or 20 weeks was significantly less likely in participants reporting opioid exposure. Exposure correlated with lower odds of skin-to-skin contact, infant being fed in the first hour, exclusive breastfeeding in the hospital, and feeding on demand. Hospital pacifier use was associated with opioid exposure.
Conclusion: While we found no difference in breastfeeding attempt, we did observe significant differences in breastfeeding duration and early hospital experiences which may represent modifiable gaps in clinical practice. Future work should focus on optimizing early hospital experiences and support when breastfeeding is clinically indicated.
Whole body massage for newborns: A report on non-invasive methodology for neonatal opioid withdrawal syndrome
Background: Infants with in-utero exposure to opioids are at risk Neonatal Opioid Withdrawal Syndrome (NOWS) and non-pharmacological methods of care, like swaddling, quiet ambient environment are routinely recommended but are not systematically studied. We hypothesized that opioid exposed infants can tolerate whole body massage while hospitalized.
Methods: This is a prospective observational study (August 2017 to January 2019) and infants of mothers having a history of opioids use (OUD) were included. Infants received whole body massage for 30 minutes from birth till discharge home. Infants heart rate (HR), respiratory rate (RR), systolic (sBP) and diastolic blood pressure (dBP) were recorded prior to and at the end of massage session.
Results: The pilot study enrolled 30 infants. The mean birth weight and gestational age were 38±1 weeks and 2868±523 grams, respectively. All massage sessions were well tolerated. There was marked decrease in HR, systolic and diastolic BP and RR, (p < 0.01) in all study infants post massage, more profound among infants with NOWS (p < 0.01) than without NOWS.
Conclusions: Whole body massage is very well tolerated by infants with in-utero opioid exposure. Infants with NOWS had marked decrease in their HR and BP from their baseline after massage.
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