Incidence Of Neonatal Abstinence Syndrome Research Articles

Evaluating Nutritional Selection and Outcomes in Neonatal Abstinence Syndrome: A Retrospective Review.

The rising incidence of neonatal abstinence syndrome (NAS) has amplified the importance of nonpharmacological interventions in its management, which include the selection of feedings. With the goal of obtaining an accurate assessment of the effects of current feeding practices in NAS infants in our neonatal intensive care unit, we conducted a retrospective review of NAS infants at our hospital over a 3-year period to determine their nutritional selections and evaluate their length of stay (LOS), length of treatment (LOT), and growth outcomes. Retrospective chart review of term infants (≥37 weeks of gestation) with NAS. Maternal and infant demographics and characteristics were recorded. Infants were grouped based on majority (>50% of total feeding) nutritional selections and LOS, LOT, and growth parameters were evaluated. Linear regression was used to compare group outcomes. Significance was set at a p-value <0.05. A total of 70 infants were included and grouped based on majority feeds into maternal breast milk (MBM), standard term formula (STF), low lactose formula (LLF), and extensively hydrolyzed formula (EHF) groups. Feeding selections were provider-dependent and infants were placed on MBM or STF as an initial selection. In all infants included in our review, LLF was selected as the first choice following MBM or STF for increased gastrointestinal (GI) disturbance-related Finnegan Neonatal Abstinence Scoring scores and changed to EHF if LLF failed to improve the GI-related symptoms. The STF-fed infants had the shortest LOS, and none of these infants required pharmacological treatment. The LOT and LOS were similar in the MBM- and LLF-fed groups. Infants who were EHF fed had the longest LOT and LOS. All feeding groups demonstrated appropriate growth. Nutritional selections in our NAS infants were modified for the severity of their withdrawal symptoms. All nutritional modifications driven by severity of withdrawal symptoms supported favorable growth outcomes in the infants. · Our NAS infants were fed with multiple types of nutrition.. · Infants with severe NAS required more elemental feeds.. · All formula selections supported favorable growth..

Association Between Clubfoot and Neonatal Abstinence Syndrome in the United States, 2018-2022.

The United States has seen an increase in opioid use and misuse over the last 2 decades. Infants have been impacted by the opioid epidemic, with a reported 5-fold increase in the incidence of neonatal abstinence syndrome (NAS) over the last 2 decades. There are many conditions associated with NAS, and thus, the current study sought to examine the association between NAS and clubfoot. The study was retrospective, utilizing patient data from the Pediatric Hospital Information System (PHIS) database. Neonates presenting to any PHIS hospital between 2018 and 2022 were identified and included in the study. Patients with NAS and clubfoot were identified utilizing the International Classification of Diseases (ICD)-9 and 10 codes. Univariable and multivariable analyses were performed to investigate associations between clubfoot, race, ethnicity, insurance type, gestational age, length of stay, NAS, and comorbidity burden. A total of 458,274 patients were identified, of whom 2337 (0.5%) had a clubfoot diagnosis and 5431 (1.2%) had a diagnosis of NAS. Multivariable logistic regression revealed higher independent odds of clubfoot among patients with a diagnosis of NAS [odds ratio (OR): 1.49], patients with a greater number of comorbidities (OR: 4.75 for 1 comorbidity vs. none, and 21.19 for 2+ comorbidities, vs. none), patients with a greater gestational age (OR: 1.01 per week increase), and those with an increased length of stay (OR: 1.00 per day increase). A lower independent odds of clubfoot was observed among patients of Asian race (OR: 0.66), Hispanic/Latino ethnicity (OR: 0.80), non-Hispanic Black (OR: 0.75), and multiracial (OR: 0.80) ethnicity/race relative to non-Hispanic/Latino White patients (P<0.05 for all). Patients with a diagnosis of NAS demonstrated higher odds of clubfoot, in addition to sociodemographic factors, as well as comorbidity burden.

Evaluating the Impact of Eat, Sleep, Console in Neonatal Abstinence Syndrome Treatment for Infants Exposed to Substance Use In Utero

OBJECTIVE An increase in maternal use of licit or illicit substances, alcohol, and tobacco has resulted in an increased incidence of neonatal abstinence syndrome (NAS). In recent years, NAS management has shifted to initiating an Eat, Sleep, Console (ESC) approach prior to pharmacologic treatment. The objective of this study was to evaluate the impact of ESC in combination with pharmacologic treatment in the management of NAS for infants exposed to substance use in utero. METHODS This single system, multisite, retrospective cohort study evaluated infants with known exposure to substance or polysubstance use in utero or those who had signs and symptoms of withdrawal with a positive toxicology screen. The primary outcome of rate of pharmacologic therapy initiated was evaluated pre and post implementation of ESC. Secondary outcomes included hospital length of stay, day of life that pharmacologic therapy was initiated, and an evaluation of the ESC guideline. A subgroup analysis with similar outcomes was also performed for patients with maternal polysubstance use. RESULTS A total of 2843 patients were screened, and 50 patients were randomly selected for ­inclusion in both pre- and post-groups. The rate of pharmacologic therapy initiated post implementation of ESC decreased from 58% to 30% (p &amp;lt; 0.01). In the post-group, there was a decrease in the number of ­patients requiring scheduled morphine (33%, p &amp;lt; 0.01) and duration of pharmacologic therapy (14.6 days vs 6.47 days, p &amp;lt; 0.01). CONCLUSIONS Implementing an ESC guideline decreased the length of stay and rate of pharmacologic intervention needed for infants with NAS at our institution.

Assessment of risk factors for Neonatal Abstinence Syndrome (NAS) using a Standardized Surveillance Case Definition in Clark County, NV

Background: Neonatal Abstinence Syndrome (NAS) is a withdrawal syndrome in neonates that can occur due to drug exposure during pregnancy. This study had two objectives: (1) Assess the implementation of the Council of State and Territorial Epidemiologists (CSTE) Tier 2 case definition for NAS surveillance in Clark County, Nevada and (2) Identify risk factors for NAS. Subjects and Method: This study utilized hospital discharge data. Claim-based records from non-federal acute care hospitals located in Clark County during 2016-2022 were analyzed. All newborn inpatient discharge records from January 1, 2016 to September 30, 2022 in Clark County, Nevada were selected. ICD-10-CM codes were utilized based on the CSTE Tier 2 case definition. Any neonate record that met the case definition, including any record with the diagnosis code P96.1, was considered a NAS confirmed case. Codes for suspect cases, maternal history of substance use, unspecified maternal medication, and transmitted noxious-substances were also assessed. A multiple logistic regression model using backward stepwise selection was developed to find risk factors related to NAS-confirmed births. Results: In Clark County, Nevada, the NAS incidence rate from January 2016 to September 2022 was 7.4 per 1,000 births. In 2022 alone, the rate of NAS was 8.9 per 1,000 births. Estimated rates of NAS were highest among neonates who were White at 13 per 1,000 births. Hospital J, the largest academic medical center in Southern Nevada, had the highest NAS confirmed case rate at 11.3 per 1000 newborn hospitalizations. Results from the multiple logistic regression model showed the odds of being born with NAS among neonates who identified as White were 5.0 (OR=5.17; 95% CI= 4.29 to 6.24; p &lt;0.001) times more likely to have NAS compared to the Hispanic group. Conclusion: Given that 2022 had the highest rate of confirmed NAS cases there is a need to collect substance and diagnosis-specific data about prenatal substance use to identify unmet service care and disparities. Keywords: neonatal abstinence syndrome, opioids, substance dependence. Correspondence: Cassius Lockett. Southern Nevada Health District. 280 S Decatur Blvd, Las Vegas, NV 89107. lockett@snhd.org. 702-759-1691.

Assessment of the Standardized Surveillance Case Definition for Neonatal Abstinence Syndrome by the Council of State and Territorial Epidemiologists, 4 Jurisdictions, 2020-2021

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.

Current Research on Opioid Use Disorder (OUD) in Pregnancy with Emphasis on Medication Assisted Treatment (MAT)

Substance use disorder in pregnancy is a major obstetric issue, with significant maternal and fetal morbidity and mortality. The incidence of opioid use disorder has risen substantially in the United States, with overdose now a leading contributor to pregnancy related deaths. Medication assisted treatment for opioid use disorder can improve pregnancy outcomes, with Methadone, and more recently Buprenorphine becoming the mainstays of treatment. There is decreased incidence of neonatal abstinence syndrome with maternal Buprenorphine use, as well as possible decreased association with neonatal low birth weight. Despite the known benefits of treatment, there remain barriers to medication assisted treatment, including clinician stigma and lack of familiarity with pharmacology. The American College of Obstetrics and Gynecology maintains a firm stance on the benefits of treatment during pregnancy, in order to avoid the known adverse outcomes associated with substance abuse during pregnancy. Pregnancy is period when most women routinely seek healthcare, and thus allows the opportunity for obstetrical providers to optimize maternal well-being. The goals during pregnancy remain the same as those outside of pregnancy: For medication treatment to assist in the prevention of a chronic and remitting condition that can result in overdose, and provide a gateway towards long-term recovery.

Policies Affecting Pregnant Women with Substance Use Disorder

Policies Affecting Pregnant Women with Substance Use Disorder

Reduction of racial disparities in urine drug testing after implementation of a standardized testing policy for pregnant patients

Drug use during pregnancy can have implications for maternal and fetal morbidity and mortality and legal ramifications for patients. The American College of Obstetricians and Gynecologists guideline states that drug screening policies during pregnancy should be applied equally to all people and notes that biological screening is not necessary, stating that verbal screening is adequate. Despite this guidance, institutions do not consistently implement urine drug screening policies that reduce biased testing and mitigate legal risks to the patient. This study aimed to evaluate the effects of a standardized urine drug testing policy in labor and delivery on the number of drug tests performed, self-reported racial makeup of those tested, provider-reported testing indications, and neonatal outcomes. This was a retrospective cohort study. A urine drug screening and testing policy was introduced in December 2019. The electronic medical record was queried for the number of urine drug tests performed on patients admitted to the labor and delivery unit from January 1, 2019, to April 30, 2019. The number of urine drug tests performed between January 1, 2019, and April 30, 2019, was compared with the number of urine drug tests performed between January 1, 2020, and April 30, 2020. The primary outcome was the proportion of urine drug tests performed based on race before and after the implementation of a drug testing policy. The secondary outcomes included total number of drug tests, Finnegan scores (a proxy for the neonatal abstinence syndrome), and testing indications. To understand perceived testing indications, pre- and postintervention provider surveys were administered. Chi-square and Fisher exact tests were used to compare categorical variables. The Wilcoxon rank-sum test was used to compare nonparametric data. The Student t test and 1-way analysis of variance were used to compare means. Multivariable logistic regression was used to construct an adjusted model that included covariates. In 2019, Black patients were more likely to undergo urine drug testing than White patients, even after adjusting for insurance status (adjusted odds ratio, 3.4; confidence interval, 1.55-7.32). In 2020, there was no difference in testing based on race after adjusting for insurance status (adjusted odds ratio, 1.3; confidence interval, 0.55-2.95). There was a reduction in the number of drug tests performed between January 2019 and April 2019 compared with between January 2020 and April 2020 (137 vs 71; P<.001). This was not accompanied by a statistically significant change in the incidence of neonatal abstinence syndrome measured by mean Finnegan scores (P=.4). Before the implementation of a drug testing policy, 68% of providers requested patient consent for testing; after the implementation of a drug testing policy, 93% requested patient consent for testing (P=.002). The implementation of a urine drug testing policy improved consent for testing and reduced disparities in testing based on race and the overall rate of drug testing without affecting neonatal outcomes.

Neonatal Abstinence Syndrome: Non-pharmacologic Interventions for the Maternal-Infant Dyad

Neonatal Abstinence Syndrome (NAS) remains a concern for health care providers. The incidence of NAS has increased globally, and it has emerged as a worldwide health concern. In our previous article, we explored the efficacy of current pharmacologic treatment for NAS symptoms. Our purpose now is to focus on non-pharmacologic interventions for NAS symptoms and the involvement of caregivers, specifically the mother. We will discuss breastfeeding, rooming in, babywearing, the eat, sleep, console approach, and laser acupuncture. We intend to describe the involvement of the interdisciplinary team and all who care for these infants, including parents.

Quality Improvement Targeting Non-pharmacologic Care and As-needed Morphine Improves Outcomes in Neonatal Abstinence Syndrome.

We developed a protocol for NAS treatment emphasizing early transfer to general pediatric units, maximization of non-pharmacologic care, and use of as-needed morphine whenever pharmacologic treatment is required. Outcome metrics were the day of life at discharge and cumulative morphine exposure. As a process measure, we also monitored the day of life at transfer to general pediatric units. In addition, we utilized statistical process control charts to track changes in performance. Twenty-eight patients met the inclusion criteria for analysis over 24 months following project initiation. Day of life at discharge decreased by 61% (20.0 versus 7.89 days, P < 0.001), and cumulative morphine exposure decreased by 81% (13.66 versus 2.57 mg morphine, P ≤ 0.001). Day of life at transfer to general pediatric units decreased by 49% (11.13 versus 5.7 days, P = 0.002). There were no readmissions or other identified adverse events. We achieved significant improvements in NAS outcomes using improved non-pharmacologic care and as-needed morphine. Moreover, the improvement did not require transitioning to a new scoring system. These results support the efficacy and safety of as-needed morphine for NAS management.

A population-based descriptive study of neonatal abstinence syndrome using hospital discharge and birth certificate data

ABSTRACT Background Neonatal abstinence syndrome (NAS), largely a consequence of prenatal opioid exposure, results in substantial morbidity. Population-based studies of NAS going beyond Medicaid populations and hospital discharge data (HDD) alone are limited. Using statewide Tennessee (TN) HDD and birth certificate (BC) data, we examined trends and evaluated maternal and infant factors associated with NAS. Methods We conducted a population-based descriptive study during 2013–2017 in TN. NAS infants were identified with International Classification of Diseases (ICD)-9-Clinical Modification (CM) and ICD-10-CM codes in HDD and linked to BC data using iterative deterministic matching algorithms. Descriptive analyses were conducted for infant and maternal factors (exposures) by NAS (outcome). Multivariable logistic regression models were used to estimate adjusted ORs and 95% CIs. Results NAS incidence increased from 13.4 to 15.4 per 1,000 live births between 2013 and 2017 (15% increase; ptrend <0.001), but remained stable in 2017. In adjusted models, maternal factors associated with reduced odds of NAS included breastfeeding (OR:0.55, 95%CI:0.52–0.59) and prenatal care (OR:0.36, 95%CI:0.32–0.41). Smoking, preterm birth, and lower birthweight were associated with increased odds of NAS. Conclusions This study highlights the value of utilizing surveillance data to monitor trends and correlates of NAS to inform prevention efforts and targeting of public health resources.

Neonatal Opioid Withdrawal Syndrome

Opioid use, both prescribed and illicit, has grown exponentially in the United States since the late 1990s, and with it, opioid use during pregnancy and neonatal abstinence syndrome (NAS) have also increased. NAS is a withdrawal syndrome occurring in newborns that results from maternal opioid use during pregnancy and has variable onset, severity, and duration. Given the increasing incidence of NAS, this article seeks to review its definition, presentation, evaluation, and management to ensure adequate care of these infants and families. [ Pediatr Ann . 2022;51(6):e234–e242.]

In Utero Morphine Exposure Induces Hypertension And Opioid Receptor‐Mediated Angiotensin II Sensitization

Opioid use disorder (OUD) is associated with nearly two‐fold increased risk of cardiovascular disease, metabolic syndrome and diabetes. OUD by pregnant women is an understudied area related to the opioid epidemic leading to increased incidence of neonatal abstinence syndrome (NAS) and neonatal opioid withdrawal syndrome (NOWS). There is an interaction between the Renin‐Angiotensin System (RAS) and the endogenous opioid system (EOS) commonly associated with the development of hypertension. This study tests the hypothesis that in utero opioid exposure induces hypertension and increases vascular reactivity to Angiotensin‐II (AngII) in the adult offspring. Sprague Dawley dams were treated with escalating doses of a mu‐opioid receptor agonist morphine (MOR, 5‐20mg/kg/day, s.c) or saline (VEH). Weight gain was not different between MOR and VEH‐exposed pregnant rats (F‐MOR 100.2±9.5 vs F‐VEH 95±10 g, n=4, p=NS). Additionally, litter size was not different (F‐MOR13.75±0.2 vs F‐VEH 12.25±1.8 pups, n=4, p=NS). However, MOR‐exposed females exhibited low birth weight (F‐MOR 5.6±0.2 vs F‐VEH 7.2±0.6 g, n=20‐22, p&lt;0.05). Both MOR‐exposed male and female offspring weighed less at weaning compared to VEH‐exposed offspring (p&lt;0.05). At 16 weeks on CHOW diet, only MOR‐exposed female offspring continue to weigh significantly less than VEH‐exposed offspring (F‐MOR 264.5±9.7 vs F‐VEH 306.5±14 g, n=14‐16, p&lt;0.05). Furthermore, both MOR‐exposed male and female rats are hypertensive (M‐MOR 127±0.84 vs M‐VEH 110±1.45 mmHg, p&lt;0.05; F‐MOR 115.2±0.49 vs F‐VEH 93.5±0.50 mmHg, p&lt;0.05). MOR‐exposed offspring displayed exacerbated acute pressor response to Angiotensin II (AngII, 0.01‐1 ng/Kg, intraarterial), the effect was greater in MOR‐exposed males than in females. Additionally, MOR‐exposed females show impaired maximal relaxation in response to acetylcholine (Ach, 10‐5 to 10‐9 M, F‐MOR 22.2±6 vs F‐VEH 44.7±4 %, p&lt;0.05) but not MOR‐exposed males. However, only MOR‐exposed males show exacerbated maximal AngII‐induced vasoconstriction (M‐MOR 49.4±4 vs M‐VEH 35.8±3.9 %, p&lt;0.05), which was blunted by an opioid receptor antagonist preincubation (naloxone, 1mM, 10 min, M‐MOR=49.4±4 vs M‐MOR+NAL 34.1±2.2 % max constriction, p&lt;0.05; M‐VEH=35.8±3.9 vs M‐VEH+NAL=45.7±4 % max constriction, p=NS). At 16 weeks on high fat diet (HFD, 60% kcal from fat), male MOR‐exposed offspring displayed weight gain in response to HFD (M‐MOR 556.4±27 vs M‐VEH 598.3±12.4 g, p=NS), while female MOR‐exposed offspring were resistant to show diet‐induced obesity (F‐MOR 295.1±13 vs F‐VEH 350.6±22 g, p&lt;0.05). HFD impaired maximal relaxation in response to acetylcholine in VEH‐exposed females (F‐VEH 44.7±4 vs. F‐VEH+HF 19±5 %, p&lt;0.05) and MOR‐exposed males relaxation (M‐MOR 49.4±4 vs M‐MOR+HF 31.2±3 %, p&lt;0.05) but not VEH‐exposed males or MOR‐exposed females. Furthermore, circulating AngII was increased in MOR‐exposed males (p&lt;0.05 vs VEH). Maternal MOR exposure increases the risk of outcomes linked to cardiovascular and metabolic disease in adult offspring. The effects appeared to be mediated through a sex‐specific mechanism in hypertension development involving potential crosstalk between AngII and the EOS.

Contribution of pharmaceutical drugs of dependence to the incidence of neonatal abstinence syndrome in Western Australia between 2003 and 2018.

Study objectiveThe aim of this study was to examine the incidence of neonatal abstinence syndrome (NAS) in Western Australia (WA) and estimate the contribution of pharmaceutical drugs of dependence (PDD) to NAS.DesignA population‐based birth cohort study.Data sourceNeonates were identified through the Midwives Notification Scheme. Linked medication dispensing and hospital records were used to identify exposure to PDD and NAS diagnosis.PatientsAll live born neonates born in WA between 2003 and 2018.MeasurementsThe incidence of NAS and percentage of NAS diagnoses associated with exposure to PDD.Main resultsDuring the study period, the incidence of NAS did not significantly change (annual percentage change (APC): 0.6, 95%CI: −1.3, 2.6), with 3.8 neonates per 1,000 live births diagnosed with NAS. PDD were dispensed to 41.4% of mothers of neonates with NAS, with PDD used to treat opioid use disorders the most commonly prescribed (35.2% of neonates with NAS), while opioid PDD used in the treatment of pain contributed to 5.2% of NAS cases. Non‐opioid PDD contributed to 1.7% of cases of NAS. The incidence of NAS associated with the use of opioids used to treat opioid use disorders (OUD) decreased over the study period (APC: −6.5, 95%CI: −9.5, −3.4), while NAS associated with opioids used to treat pain remained stable (APC: −2.7, 95%CI: −7.1, 1.9).ConclusionThe incidence of neonatal abstinence syndrome in WA remained stable from 2003 to 2018. Medications used to treat opioid use disorders were a substantial driver of NAS, although NAS associated with these medications has declined over time.

Neonatal Abstinence Syndrome in North Carolina: Incidence and Characteristics among Infants and Mothers.

BACKGROUND Neonatal abstinence syndrome (NAS) is a complex disorder characterized by withdrawal symptoms secondary to in utero exposure to drugs capable of producing physical dependence. The objective of this study was to determine the incidence of NAS, as well as infant and maternal characteristics associated with NAS in North Carolina (NC).METHODS This retrospective, cross-sectional, observational study used the State Inpatient Database (SID) to compare the incidence rates of NAS for NC for the year 2016 to historical data (years 2000 to 2013). A multivariable logistic regression model including available covariates of interest was constructed.RESULTS Overall NAS incidence rate (IR) for NC was found to be 9.7 per 1,000 live births, a 32.3-fold increase since 2000 (IR=0.3 in 2000). The multivariable logistic regression model suggested race group (both black [OR 0.11; 95% CI: 0.08, 0.16] and 'other' [OR 0.43; 95% CI: 0.31, 0.61] vs white), ethnicity [OR 0.43; 95% CI: 0.31, 0.61], insurance group (both 'other/self-pay' [OR 0.35; 95% CI: 0.24, 0.52] and 'private insurance' [OR 0.07; 95% CI: 0.05, 0.10] vs Medicaid/Medicare), region (Piedmont [OR 0.62; 95% CI: 0.50, 0.79] vs Mountain), income quartile (both 4th [OR 0.45; 95% CI: 0.26, 0.79] and 3rd [OR 0.70; 95% CI: 0.50, 0.96] vs 1st), county population size (50k-249k [OR 0.54; 95% CI: 0.34, 0.86] vs ≥1 million), birth weight [OR 0.87; 95% CI: 0.78, 0.98], and length of stay [OR 1.23; 95% CI: 1.20, 1.26] as potentially important predictors of NAS.LIMITATIONS Only hospitals providing data to the SID for 2016 were included and ICD-9 codes, in use at the time of data collection, were used.CONCLUSIONS The incidence of NAS has increased in NC in 2016 compared to prior years spanning back to 2000. Specific infant and maternal characteristics including race, ethnicity, payer type, geographic region, county population, parental income status, birth weight, and length appear to be associated with an infant bearing the diagnosis of NAS.

Comparison of Two Morphine Dosing Strategies in the Management of Neonatal Abstinence Syndrome.

The incidence of neonatal abstinence syndrome (NAS) has increased in recent years. Treatment approaches usually involve opioid replacement; however, the optimal treatment strategy is unknown. This study sought to determine the impact of weight- and symptom-based morphine dosing strategies on LOS and medication exposure in patients with NAS. A retrospective review was conducted from May 2015 to June 2017 at 2 NICUs within a health-system using different dosing approaches for NAS. Data were compared using Fisher exact tests for categorical data and t tests and Wilcoxon ranked sums for continuous data. Baseline demographics were well-matched except for postmenstrual age at morphine initiation (p = 0.04). The weight-based group had a larger initial morphine dose (p < 0.001) and fewer number of steps to maximum morphine dose (p = 0.009). There were no differences between groups in LOS, number of dose adjustments, doses administered, weaning steps, maximum dose, or need to re-escalate dosing. There was also no difference between the first 3 modified Finnegan scores (MFS) after transferring patients to a neonatology service. Neonates with symptom-based dosing had a higher maximum MFS (p = 0.024). Neonates in the symptom-based group required adjunct therapy more often (p < 0.0001). Data indicate the dosing strategy impacts number of steps to reach maximum dose and need for adjunctive therapy. Weight-based dosing may decrease the number of steps required to reach the morphine maximum dose and the need for adjunctive therapy by controlling NAS symptoms earlier.

Implementation of Interprofessional Rounds Decreases Neonatal Abstinence Syndrome Length of Stay.

Neonatal abstinence syndrome (NAS) occurs due to abrupt discontinuation of chronic fetal exposure to substances used by the mother during pregnancy. As the incidence of NAS continues to increase, medical teams are evaluating strategies to reduce length of stay (LOS). Increased LOS contributes to poorer mother-infant bonding and neurodevelopmental outcomes as well as increased health care cost. As part of an ongoing quality improvement project, the objective of this study was to determine if formal interprofessional rounds affected LOS for infants with NAS. This was a retrospective analysis at a single hospital system to determine if interprofessional rounds had an impact on NAS LOS. On February 5, 2016, introduction of formal weekly interprofessional NAS-specific rounds occurred in addition to daily patient care rounds. Every patient with opioid exposure undergoing Finnegan scoring, treated with weight-based morphine, and >35 weeks gestation was included. Data were collected on LOS and length of therapy for eligible patients. This study evaluated the impact of interprofessional rounds on LOS 17 months after its implementation compared with 13 months immediately preceding. Among the 119 infants (51 pre and 68 post) meeting inclusion criteria, the median LOS for the post-rounds group was significantly shorter than the pre-rounds group (13 vs 16 days, p = 0.001). The median length of therapy (morphine with or without clonidine) was also significantly shorter in the post-rounds versus the pre-rounds group (8 vs 12 days, p = 0.001). Formal weekly interprofessional NAS rounds decreased LOS and length of therapy.

Evaluation of State-Led Surveillance of Neonatal Abstinence Syndrome - Six U.S. States, 2018-2021.

Opioid use disorder (OUD) is a significant public health problem in the United States, which affects children as well as adults. During 2010-2017, maternal opioid-related diagnoses increased approximately 130%, from 3.5 to 8.2 per 1,000 hospital deliveries, and neonatal abstinence syndrome (NAS) increased 83%, from 4.0 to 7.3 per 1,000 hospital deliveries (1). NAS, a withdrawal syndrome, can occur among infants following in utero exposure to opioids and other psychotropic substances (2). In 2018, a study of six states with mandated NAS case reporting for public health surveillance (2013-2017) found that mandated reporting helped quantify NAS incidence and guide programs and services (3). To review surveillance features and programmatic development in the same six states, a questionnaire and interview with state health department officials on postimplementation efforts were developed and implemented in 2021. All states reported ongoing challenges with initial case reporting, limited capacity to track social and developmental outcomes, and no requirement for long-term follow-up in state-mandated case reporting; only one state instituted health-related outcomes monitoring. The primary surveillance barrier beyond initial case reporting was lack of infrastructure. To serve identified needs of opioid- or other substance-exposed mother-infant dyads, state health departments reported programmatic successes expanding education and access to maternal medication for opioid use disorder (MOUD), community and provider education or support services, and partnerships with perinatal quality collaboratives. Development of additional infrastructure is needed for states aiming to advance NAS surveillance beyond initial case reporting.

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

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

Alterations in Excitatory and Inhibitory Synaptic Development Within the Mesolimbic Dopamine Pathway in a Mouse Model of Prenatal Drug Exposure.

The rise in rates of opioid abuse in recent years in the United States has led to a dramatic increase in the incidence of neonatal abstinence syndrome (NAS). Despite improved understanding of NAS and its acute symptoms, there remains a paucity of information regarding the long-term effects of prenatal exposure to drugs of abuse on neurological development. The primary goal of this study was to investigate the effects of prenatal drug exposure on synaptic connectivity within brain regions associated with the mesolimbic dopamine pathway, the primary reward pathway associated with drug abuse and addiction, in a mouse model. Our secondary goal was to examine the role of the Ca+2 channel subunit α2δ-1, known to be involved in key developmental synaptogenic pathways, in mediating these effects. Pregnant mouse dams were treated orally with either the opioid drug buprenorphine (commonly used in medication-assisted treatment for substance use patients), gabapentin (neuropathic pain drug that binds to α2δ-1 and has been increasingly co-abused with opioids), a combination of both drugs, or vehicle daily from gestational day 6 until postnatal day 11. Confocal fluorescence immunohistochemistry (IHC) imaging of the brains of the resulting wild-type (WT) pups at postnatal day 21 revealed a number of significant alterations in excitatory and inhibitory synaptic populations within the anterior cingulate cortex (ACC), nucleus accumbens (NAC), and medial prefrontal cortex (PFC), particularly in the buprenorphine or combinatorial buprenorphine/gabapentin groups. Furthermore, we observed several drug- and region-specific differences in synaptic connectivity between WT and α2δ-1 haploinsufficient mice, indicating that critical α2δ-1-associated synaptogenic pathways are disrupted with early life drug exposure.