Background: In East Tennessee and Middle Appalachia, the epicenter of the opioid epidemic, approximately 15% of women give birth taking buprenorphine or methadone for opioid addiction (medical assisted therapy--MAT) or using other drugs illicitly and 5% of births are diagnosed with neonatal abstinence syndrome (NAS). A better understanding is needed of factors contributing to the severity of NAS. Objective: To identify maternal and infant characteristics associated with length of stay among newborns with neonatal abstinence syndrome. Design/Methods: Participants were 150 newborns systematically sampled from births diagnosed with NAS during the past 5 years at a single medical center. Data were obtained through abstraction of maternal prenatal records, infant delivery and infant medical charts. The abstraction included maternal and child demographic and clinical characteristics. Drug and other substance use/exposure histories were based on maternal history, and urine and cord tissue drug screening. Results: The infants’ average length of stay was 18.6 (s.d. = 11.9), 15% were low birthweight, and had an average gestational age of 38.8 (s.d. = 1.8); 62% were male; 49% were breast-fed. The mothers mean age was 27.5 (s.d. = 5.0); mean parity was 1.6 (s.d. = 1.4); 77% were unmarried; 75% had < HS education; and 89% had exposure at some time during pregnancy to other prescription (in addition to buprenorphine or methadone) or illicit opioids. In the least squares regression, which included important potential covariates such as infant sex, birth weight and gestational age, significant predictors of infant length of stay include: maternal benzodiazepine use (8.3 day longer LOS on average; p = 0.019), and infants whose mothers had a history of mental illness (3.9 day longer LOS on average, p = 0.040 ). While infants born to mothers smoking in the final 30 days of pregnancy had a 2.7 day longer LOS on average after adjustment for other significant predictors, this association was no longer significant in regression analysis (p = 0.293). Conclusion(s): Maternal use of prescription or illicit opioids leading to NAS is rooted in women’s’ life histories characterized by disadvantage, relationship instability, polysubstance use and mental illness. Efforts to reduce the incidence and severity of NAS among those on MAT during pregnancy should focus on preventing poly-substance misuse and providing supports for other maternal health needs including treating mental illness.

There are currently no published scoring instruments with prior empirical evidence to support the validity and reliability of the accuracy of the drug withdrawal scores generated in infants greater than 28 days of life with a diagnosis of Neonatal Abstinence Syndrome (NAS). This study was done to identify the signs of withdrawal in infants greater than 28 days of life with NAS and determine if further adaptation of the modified-FNAST was necessary to accurately measure the severity of drug withdrawal in this sub population of infants. This aim could not analyzed due to limitations of the data. The study was also done to describe the relationship between the medications used to treat the infant NAS and the longitudinal trajectory of the Finnegan scores. The results of the study revealed that the total modified-FNAST scores ranged from 0-21 on day 1 of life with a mean of 8.68 and a SD (4.127), and then gradually decreased with less variability over the length of the hospitalization until discharge. Four medications were used to treat the infants for NAS. The medications used to treat the infants for NAS included morphine (99%), phenobarbital (66.2%), clonidine (25.1%), and buprenorphine (1.9%). The minimum to maximum dosage and minimum to maximum duration of inpatient treatment days for each of the medications were explored and revealed, morphine (dosage range, 0.33-2.170 mg/kg/day and duration of 14-81 days), buprenorphine (dosage range 7.00-61.30 mcg/kg/day and duration of 4.00-30.00 days), clonidine (dosage range 3.97-28.93 mcg/kg/day and duration of 16.00-87.00 days), and phenobarbital (dosage range 3.00-16.00 mg/kg/day and duration of 2.00-84.00 days). Most of the infants received morphine alone or in combination with phenobarbital or clonidine consistent with the established evidence-based NAS weaning protocol. The Mixed Effects Model Analysis revealed that there was an overall decrease in the total Finnegan scores over time (p < 0.0001). The mean total Finnegan scores showed a statistically significant difference in the groups treated with and without clonidine (p = 0.0031). The group treated with clonidine had higher mean total Finnegan scores. The infants treated with phenobarbital did not show a significant association with the total Finnegan scores (p = 0.6852). In addition, all other control variables failed to show significant associations with the repeated measures of total Finnegan scores including: gender (p = 0.6257), infant birth weight (p = 0.9375), gestational age (p = 0.8444) and the estimated number of cigarettes smoked by the mother during the pregnancy (p = 0.7300). The interaction between the infants treated with clonidine and phenobarbital were not statistical significant either. (p = 0.6412). Key Words: Neonatal Abstinence Syndrome, opioid, modified-FNAST, reliable, valid, factor analysis

The prevalence of opioid use has increased in many populations including pregnant women, which has led to a substantial rise in infants born dependent on opioids due to in utero exposure. Many women use multiple substances aside from opioids during pregnancy, and their infants therefore present with a variety of symptoms. With increasing legalization and changing perception of marijuana, it has become one of the most commonly used substances during pregnancy. Few studies have evaluated concomitant use of marijuana and opioids in pregnancy despite both being implicated in adverse newborn outcomes. The primary aim of this study was to determine the association between marijuana use and pregnancy outcomes in opioid-exposed pregnancies. The secondary aim was to identify, in a sample of women already using opioids, maternal characteristics associated with marijuana use during pregnancy. A retrospective chart review was conducted from July 2011 to June 2016 of all births from 6 delivery hospitals in South-Central Appalachia to determine pregnancy and neonatal outcomes of pregnancies exposed to any form of opioid and positive urine drug screen for marijuana at the time of delivery. 2375 pregnancies met the inclusion criteria with 108 pregnancies positive for marijuana. Student t-test and Chi-Square test were used for group comparison for presence and absence of marijuana. Logistic regression was done for significant confounding variables to find aOR for marijuana exposure for neonatal abstinence syndrome diagnosis, premature birth, and low birth weight. Among opioid using women, marijuana positive women were more likely to be unmarried, nulliparous, and use tobacco and benzodiazepines. Infants born to the marijuana users were likely to be of earlier gestational age (3 days), lower birth weight, and preterm; with preterm birth and low birth weight (mean difference = 265 gms) increased two fold even after controlling for parity, marital status, tobacco and benzodiazepine use with aOR of 2.35 (1.30-4.23) and 2.02 (1.18-3.47) respectively. Ultimately, prenatal use of marijuana in opioid-exposed pregnancies carries significant risk of prematurity and low birth weight. For pregnant women continuing their American College of Obstetricians and Gynecologists recommended medical assisted treatment for opioid use disorder, providers should counsel women to abstain from marijuana during pregnancy.

The presenter will discuss challenges and implications of Neonatal Abstinence Syndrome (NAS) to classroom environment, behavior management and special education. The presenter will then open discussion on experiences with NAS in classrooms, schools, and communities.

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Introduction Neonatal abstinence syndrome (NAS) is a health condition in infants that results from the sudden discontinuation of substances that infants were exposed to in utero (Kocherlakota, 2014). Typical symptoms include: hyperirritability, sweating, hypertension, tremors, sleep deprivation, and seizures (Kocherlakota, 2014). The role of a SLP in treating infants with NAS in the NICU includes evaluation, assessment, and treatment of the feeding cycle. Our research is an early exploratory and descriptive study of the pre-natal, peri-natal, and post-natal characteristics of infants with NAS who required SLP assessment and intervention as opposed to those who did not. Our aim was to examine possible predictors of infants with feeding and swallowing difficulties. Methods Data was collected from a local hospital system that conducted a five-year retrospective chart review study. From charts of 140 infants in the NICU, infants were placed into two groups: infants who received SLP services (SLP group) and infants who did not receive SLP services (NSLP group). From those charts, 26 infants with NAS who received SLP services were placed in SLP group based on the availability of a match in NSLP group. Infants in both groups were matched based on gestational age, year of birth, and gender. Results/Conclusion There were no significant differences found between SLP group and NSLP groups in: number of prenatal visits, week/timing of initial prenatal visit, and dosage of buprenorphine taken by the mother. The two groups did not differ (all ps>.18) in their types of drug use, average dosage of buprenorphine taken, average number of prenatal visits, or average week of first visit. There was a statistically significant difference in maternal age in the SLP group (p<.05; M=29.7 years, SD=5.4) and in NSLP group (M=26.7 years, SD=4.3.). There was no statistically significant difference in initial measurements of weight, head circumference, length, Apgar scores at birth, and number of complications between groups. There were no significant differences found in NAS scores between groups regarding the highest NAS score or average NAS score, number of NAS scores and first day of collection or number of days collected. There was a statistically significant difference in the number of prescription drugs administered. Infants in SLP group had more prescription drugs on average (M=1.50, SD=.89) than NSLP group (M=1.04, SD=.20). There was a statistically significant difference in the amount of weight gained (SLP group gained 229 more grams) and in infant length of stay and overall cost (SLP group on average stayed in the NICU one week longer and cost $22,896 more). Little research has been conducted regarding NAS and the impact it has on feeding and swallowing. We found that there are statistically significant differences among infants who were in SLP and NSLP groups. It cannot be determined how many full-term infants have dysphagia; however, from a clinical opinion it is thought that most full-term babies with dysphagia also have a neurological impairment.

Background: Neonatal Abstinence Syndrome (NAS), a manifestation of the widespread opioid epidemic, has plagued our country, and particularly the region of Northeast Tennessee, for quite some time now. One question among many that seems to baffle almost everyone involved in research on the topic at hand is that why do only 35-40% of opioid exposed pregnancies result in NAS requiring medication while sparing the rest. Is there some discriminatory factor other than in utero opioid exposure involved? Thus, in light of this knowledge, we wanted to investigate whether birth weight at the time of delivery can influence the development of NAS; that is, are neonates of a low birth weight or high birth weight (with respect to gestational age thresholds) more likely to develop NAS. Methods: Therefore, we conducted a retrospective chart analysis of all deliveries within the Mountain States Health Alliance System over a 5 years period between July 1, 2011- June 30, 2016 at all 5 delivery sites in Northeast Tennessee and Southwest Virginia (N=18,728). Out of this sample size, we identified 2,392 at-term newborns as positive for prenatal opioid exposure, and then we stratified them into 2 categories: birth weight ≤3.5kg (proxy for low or average birth weight with respect to gestational age thresholds) and birth weight ≥3.5kg (proxy for high birth weight with respect to gestational age thresholds). Thereafter, we ran SPSS statistical analyses involving chi square, t tests, and logistic regression to assess whether one birth weight group was more likely to have a higher incidence rate of NAS compared to the other birth weight group. Results: We found that even after controlling for significant confounders such as marital status, race, and pregnancy smoking, benzodiazepine, and marijuana use, infants who were in the low to average birth weight group (≤3.5kg in this study) were almost twice as likely (statistically significant adjusted odds ratio of 1.95) to develop NAS compared to infants who were in the high birth weight group (≥3.5kg in this study). Our study helps shed some important light on the discriminatory factors for NAS development, with birth weight being a significantly associated clinical factor as we now know. Discussion & Implications: Unfortunately, the mechanism for the transport of opioids across the placenta is complicated, and poorly understood. There may be more ‘unbound or free opioids’ available in infants of low to average birth weight (with respect to gestational age thresholds) compared to infants of high birth weight (with respect to gestational age thresholds) resulting in a higher incidence of NAS in the former population. It is more of a speculation rather than a conclusion to explain the results of our study. However, being equipped with this knowledge that opioid exposed neonates of low to average birth weight (with respect to gestational age thresholds) have a higher risk of developing NAS will allow physicians to identify infants with a higher risk for NAS early, and this will subsequently lead to better outcomes and reduced severity in cases of NAS.