Neonatal Abstinence Syndrome (NAS) is the condition which occurs when newborn babies experience withdrawal symptoms from medications taken by their mothers during pregnancy. Prior research suggest NAS is associated with long-term educational difficulties and alterations in neonatal brain structure. Between 2008 and 2017, NAS rates more than tripled in the United States. An epicenter of the NAS epidemic is Southern Appalachia. West Virginia, the only state with all counties located in Southern Appalachia, has an NAS rate roughly seven times the national average, and in 2017, four of the 10 states with the highest NAS rates were part of Southern Appalachia. Upon reviewing Tennessee data, it was noted that increasing NAS rates had a similar curve to buprenorphine prescribing patterns. Buprenorphine is an opioid partial-agonist prescribed in medication assisted therapy (MAT) intended to help individuals, including those pregnant, avoid withdrawal symptoms. Previous research at an East Tennessee clinic identified buprenorphine in urine drug screens of 16% of all pregnant patients; patients admit to both prescribed and illicit use, including snorting, smoking, and injecting. These findings align with a 2017 study suggesting that mothers of NAS infants in eastern Tennessee, compared to mothers across the state, were more likely to use substances prescribed to another person. Despite the drug’s increasing prescribing patterns and popularity for illicit use, its effects on the mother and fetus remain controversial. We therefore felt it appropriate to investigate possible linkages between buprenorphine prescriptions and NAS rates. For the purposes of this study, we define Southern Appalachia as 250 counties from 7 states, including Tennessee, West Virginia, Virginia, North Carolina, Kentucky, Ohio, and Maryland. Annual NAS rates, buprenorphine prescription rates, drug-induced death rates, and opioid prescribing rates from each county in the region were assessed for the years 2008-2018 using data provided by governmental agencies. It was found that buprenorphine prescriptions in the region more than quintupled between 2008 and 2018. NAS rates and drug-induced death rates did not decrease as well; unfortunately, they dramatically increased. We identified a significant linear association between the rate of NAS diagnoses and buprenorphine prescriptions (r = 0.9774, R2 = 0.9553, p-value less than 0.001) and between the rate of buprenorphine prescriptions and drug-induced deaths (r = 0.7129, R2 = 0.5082, p-value .0311). This is the first report which documents a relationship between NAS rates and increasing buprenorphine prescribing. Discussions regarding current policies for buprenorphine management during pregnancy are warranted. We encourage further research on establishing the lowest effective buprenorphine dose for each patient, and we support the CDC’s resumption of tracking the morphine milligram equivalents (MME) of buprenorphine prescribed during pregnancy so that researchers can further study the effect of congenital MME exposure on fetal outcomes.

Indiana University-Purdue University Indianapolis (IUPUI) / Opioid misuse and addiction has been widely identified as a public health problem, contributing substantially to the nation’s morbidity and mortality. Over the past two decades, misuse of prescription opioids pain relievers has substantially increased; heroin use has resurged; and, more recently, abuse of high-potency synthetic opioids such as fentanyl have fueled the epidemic. Nearly 12 million Americans (or 4.4%) aged 12 and older misused some type of opioid (prescribed or illegal) in the past year. Furthermore, the percentage of substance use treatment admissions attributable to opioids nearly doubled in the U.S., from 20.8% in 2000 to 40.5% in 2015. The purpose of this dissertation research was to investigate associations between prescription pain reliever use and subsequent negative health outcomes, including opioid misuse or addiction, and neonatal abstinence syndrome. This research focused on three specific aims: Specific Aim #1: Examine heroin use among Indiana’s substance use treatment population to measure the extent, trends, and patterns of use, as well as to assess the relationship between prescription opioids and subsequent heroin use; Specific Aim #2: Analyze 2014 INSPECT (Indiana’s prescription drug monitoring program) data to identify factors that increase patients’ likelihood to engage in opioidrelated risk behaviors; and Specific Aim #3: Review U.S. trends in neonatal abstinence syndrome (NAS) incidence from 2008-2014, measure regional variability, and identify personal and environmental risk factors associated with NAS. / 2020-08-09

Indiana University-Purdue University Indianapolis (IUPUI) / Neonatal abstinence syndrome (NAS), the constellation of withdrawal symptoms experienced by neonates exposed to opioids prenatally, is an epidemic affecting an estimated 23,580 infants each year with an annual cost of $720 million. The purpose of this study was to examine factors associated with the incidence and severity of NAS as measured by the need for initiation of neonatal medication, peak medication dose, hospital length of stay (LOS), and hospital costs among newborns born to opioiddependent mothers. A retrospective review of medical records was conducted with two convenience samples: 204 infants born to mothers who used opioids during pregnancy; and 121 of these infants who required treatment with morphine to control symptoms of NAS. Data from April 2011 to September 2017 were collected from medical records of a large Midwestern hospital. Exploratory analysis and descriptive statistics were performed. Associations between independent variables and outcomes were examined using correlations, chi-square, t-tests, analyses of variance, and linear regression. Of the 204 neonates who were exposed to opioids prenatally, 121 (59%) developed symptoms of NAS requiring treatment with morphine. Neonates requiring morphine had significantly higher gestational ages than those who did not (37.7 vs 36.4 weeks; p = < .001) and their mothers were present at the neonates’ bedside a lower proportion of their total hospital stay (mean = 0.5684 of days vs 0.7384 of days; p = < .001). Compared to maternal use of buprenorphine, maternal methadone use was associated with higher peak morphine doses needed to control the neonate’s withdrawal symptoms (0.089 mg/kg versus 0.054 mg/kg; p = .023), and with longer hospital length of stay when compared to maternal use of buprenorphine and other opioid analgesics (34.2 vs. 20.8 vs. 22.5 days, respectively; p=0.02). Higher visitation time from the primary caregiver was correlated with lower hospital LOS (r = -0.421; p = < .001). Future research is needed to examine these relationships prospectively in a larger and more diverse sample. An effective response to the epidemics of opioid use during pregnancy and the incidence of NAS requires ongoing coordinated research and intervention in clinical care, public health, and health policy. / 2019-11-06

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.

No description available.

Neonatal abstinence syndrome (NAS) is a syndrome of withdrawal symptoms in newborn infants that have a history of prenatal exposure to certain substances. Affected infants may have gastrointestinal (GI) issues, such as gassiness and diarrhea. Although infants with known exposures may be monitored in the first few days of life, it is unclear how long these symptoms persist. This poster will examine GI issues in the first six months of life across four groups of infants: those with prenatal opioid exposure, those with prenatal substance exposure that does not include opioids, those with polysubstance exposure, and those without substance exposure in a pediatric clinic in northeast TN. A retrospective chart review of 600 charts of infants born from 2017—2020 was conducted with IRB approval in a pediatric clinic in rural middle Appalachia. Of these, 300 charts were selected based on known prenatal substance exposure, and the other 300 charts were randomly selected. A REDCap extraction manual was created, research assistants were trained, and % agreement was determined. Data was collected about type of prenatal substance exposure, growth, and medical conditions in the first three years of life. Infants were divided into groups by type of prenatal substance exposure for analysis. The opioid-only group included exposure to buprenorphine, methadone, or other opiates. The other (non-opioid) exposure group included exposure to marijuana, cocaine, benzodiazepines, methamphetamines, and prescription ADHD medications. The polysubstance exposure group included exposure to both opiate and non-opiate substances. The control group had no prenatal substance exposure. Analyses were performed using SAS version 9.4. Descriptive statistics showed the demographics of the sample were representative of the population in rural middle Appalachia, with a predominantly Caucasian sample of 121 females and 123 males, mostly receiving TennCare. Chi-square results showed there was only a statistically significant difference between the prenatal substance exposure groups at 2 months, X2 (3, N = 176) = 8.03, p = 0.045, but not at hospital discharge, within the first few days of life, at 1 month, 4 months, or 6 months. Infants in the opioid-only exposure group were most likely to have GI issues. These findings suggest that GI issues are more likely to occur in infants with certain prenatal substance exposures. This poster also shows a longitudinal perspective of these issues, indicating that the symptoms may persist in the first few months of life. Thus, caregivers of infants at risk for NAS may benefit with information about the long-term effects. Because the retrospective chart review is still in progress, this poster only analyzes a preliminary number of charts. Future research should also take into consideration other factors that may be associated with GI issues in this population, such as nutrition.

Neonatal abstinence syndrome (NAS) refers to the withdrawal symptoms experienced when an infant has been exposed to certain substances (e.g., opioids) in-utero, resulting in health challenges for infants. Previous studies have reported substantial variations in the clinical management of NAS, suggesting that some infants may not be receiving optimal care. High-quality clinical practice guidelines are crucial to support optimal patient outcomes and standardize care. In response, I conducted a systematic review and quality appraisal of available NAS guidelines and recommendations using the AGREE-II and AGREE-REX tools. I also developed and piloted a tool to measure family-centred care in guidelines. Most guidelines received low-quality appraisal scores on the AGREE-II and the AGREE-REX appraisals (16/20 and 10/20, respectively) and have conflicting pharmacological recommendations. Findings will improve clinicians’ awareness of the variation in the quality of guidelines and assist them to make care decisions that are from the best available evidence and family-centred.

Neonatal abstinence syndrome (NAS) in infants presents unique challenges in feeding and weight gain. The unpredictable clinical manifestations associated with the newborns withdrawal from exposure to drugs in utero can lead to costly delays in transition of the infant out of the Neonatal Intensive Care Unit (NICU).The purpose of this review of literature was to explore feeding positions and nutritional intake with the greatest impact on weight gain in infants with neonatal abstinence syndrome (NAS) following delivery. The secondary purpose was to compare the clinical manifestations of infants with NAS that influence nutritional intake and their relationship to length of time and cost of stay in the NICU. A review of literature was performed using multiple databases. Articles focusing on feeding position and nutrition intake were identified for interventions to effectively promote weight gain, while reducing clinical manifestations common in infants with NAS. Articles exploring improved feeding and weight gain in infants with NAS and reduced length of stay in the NICU were also synthesized for cost reductions to the facility. Results from 12 studies comparing various feeding positions that optimized nutrition, and reduced negative clinical manifestations in infants with NAS were synthesized for content relevant to the research questions. Results suggest a relationship between placing infants in the c-position, and side-lying position to reduce sensory stimulation, with reducing clinical manifestations for infants actively experiencing withdrawal symptoms from NAS. Providing chin and cheek support as needed, decreasing eye contact during feeding periods, and providing darker quiet environments all play an important role in allowing infants with NAS to optimize their weight gain. As previously stated, to manage nutritional intake and optimize weight gain, reduction of clinical manifestations through pharmacological and non-pharmacological interventions must be actively incorporated into the infants' plan of care.

Purpose: The purpose of this ethnographic study was to describe the culture of care and nonpharmacological nursing interventions performed by NICU nurses for infants with NAS. Background: Infants with NAS are increasingly being cared for in the inpatient hospital setting by NICU nurses. Interventions used for the care of premature and sick infants in the NICU may or may not be the exact interventions that should be used for the care of the fragile infant with NAS. Research studies on the nonpharmacological nursing care of infants with NAS encompass 5 main areas of practice: environment, adequate rest and sleep, feeding, assessment and evaluation using Finnegan scoring by nurses, and nurses as caregivers. Method: Roper and Shapira’s (2000) framework for the analysis of ethnographic data was used for this research and included participant observation, individual interviews, and the examination to existing documents. Data analysis included: (a) coding for descriptive labels, (b) sorting to identify patterns, (c) identification of outliers or negative cases, (d) generalizing constructs and theories, and (e) memoing to note personal reflection and insights. Focused ethnography allows for the articulation of research questions before fieldwork while observing and describing a culture. Results: Five themes emerged from the data: learn the baby (routine care, comfort care, environment, adequate rest and sleep, feeding), core team relationships (support, interpersonal relationships), role satisfaction (nurturer or comforter, becoming an expert), grief, and making a difference (wonderful insanity, critical to them). Implications: The results of this were a description of the culture of care provided to infants with NAS by NICU nurses and provide general recommendations to the nurse caring for an infant with NAS in the areas of environment, adequate sleep and rest, feeding, and the role of the nurse. This study also has implications for future study of evidence-based research strategies to decrease withdrawal symptoms in infants with NAS. Research is needed in the areas of clinical practice guidelines to help the bedside nurse care for these infants using current research and evidence for practice. Nursing theory and nursing education both contribute to nursing research in how to better understand the culture of care provided by nurses.

The causes and neurodevelopmental outcomes of children exposed to drugs and/or alcohol prenatally are presented. The incidence of this population is rising rapidly and appearing in increasing numbers on the caseloads of speech-language pathologists. Topics include prevalence, common drugs, Neonatal Abstinence Syndrome, longer-term neurodevelopmental outcomes, and treatment challenges.