Abstract
Extremely preterm (EP) infants frequently receive opioids and/or benzodiazepines, but these drugs' association with neurodevelopmental outcomes is poorly understood. To describe the use of opioids and benzodiazepines in EP infants during neonatal intensive care unit (NICU) hospitalization and to explore these drugs' association with neurodevelopmental outcomes at 2 years' corrected age. This cohort study was a secondary analysis of data from the Preterm Erythropoietin Neuroprotection (PENUT) Trial, which was conducted among infants born between gestational ages of 24 weeks, 0 days, and 27 weeks, 6 days. Infants received care at 19 sites in the United States, and data were collected from December 2013 to September 2016. Data analysis for this study was conducted from March to December 2020. Short (ie, ≤7 days) and prolonged (ie, >7 days) exposure to opioids and/or benzodiazepines during NICU stay. Cognitive, language, and motor development scores were assessed using the Bayley Scales of Infant Development-Third Edition (BSID-III). There were 936 EP infants (448 [48%] female infants; 611 [65%] White infants; mean [SD] gestational age, 181 [8] days) included in the study, and 692 (74%) had neurodevelopmental outcome data available. Overall, 158 infants (17%) were not exposed to any drugs of interest, 297 (32%) received either opioids or benzodiazepines, and 481 (51%) received both. Infants exposed to both had adjusted odds ratios of 9.7 (95% CI, 2.9 to 32.2) for necrotizing enterocolitis and 1.7 (95% CI, 1.1 to 2.7) for severe bronchopulmonary dysplasia; they also had a longer estimated adjusted mean difference in length of stay of 34.2 (95% CI, 26.2 to 42.2) days compared with those who received neither drug. After adjusting for site and propensity scores derived for each exposure category, infants exposed to opioids and benzodiazepines had lower BSID-III cognitive, motor, and language scores compared with infants with no exposure (eg, estimated difference in mean scores on cognitive scale: -5.72; 95% CI, -8.88 to -2.57). Prolonged exposure to morphine, fentanyl, midazolam, or lorazepam was associated with lower BSID-III scores compared with infants without exposure (median [interquartile range] motor score, 85 [73-97] vs 97 [91-107]). In contrast, BSID-III scores for infants with short exposure to both opioids and benzodiazepines were not different than those of infants without exposure. In this study, prolonged combined use of opioids and benzodiazepines was associated with a risk of poorer neurodevelopmental outcomes as measured by BSID-III at 2 years' corrected age.
Highlights
The use of analgesia and/or sedation for the smallest premature infants with the most severe illness is at the discretion of the medical team, and the overall treatment goals are to mitigate pain, agitation, and discomfort
After adjusting for site and propensity scores derived for each exposure category, infants exposed to opioids and benzodiazepines had lower BSID-III cognitive, motor, and language scores compared with infants with no exposure
Fentanyl, midazolam, or lorazepam was associated with lower BSID-III scores compared with infants without exposure
Summary
The use of analgesia and/or sedation for the smallest premature infants with the most severe illness is at the discretion of the medical team, and the overall treatment goals are to mitigate pain, agitation, and discomfort. The American Academy of Pediatrics (AAP) recognizes that neonates at greatest risk of neurodevelopmental impairment as a result of preterm birth are those most likely to be exposed to the greatest number of painful stimuli in the neonatal intensive care unit (NICU).[1] The management of discomfort and agitation remains an integral part of the care for infants in the NICU, as acute and chronic pain result in heightened stress, hyperalgesia-associated reductions in white matter and corticospinal tract fractional anisotropy, and long-term behavioral changes.[2,3,4,5,6] the AAP recommends pharmacologic and nonpharmacologic therapies for the prevention of pain associated with routine minor procedures as well as measures for minimizing pain associated with surgery and other major procedures.[1,7] This recommendation is in stark contrast to prior practice, when infants received no analgesia during surgical procedures until the 1980s.8,9. The management of discomfort and agitation remains an integral part of the care for infants in the NICU, as acute and chronic pain result in heightened stress, hyperalgesia-associated reductions in white matter and corticospinal tract fractional anisotropy, and long-term behavioral changes.[2,3,4,5,6] the AAP recommends pharmacologic and nonpharmacologic therapies for the prevention of pain associated with routine minor procedures as well as measures for minimizing pain associated with surgery and other major procedures.[1,7] This recommendation is in stark contrast to prior practice, when infants received no analgesia during surgical procedures until the 1980s.8,9 Routine administration of opioids and benzodiazepines in extremely preterm (EP) infants is not recommended due to concerns regarding safety, efficacy, and potential long-term consequences.[1,7]
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