Medscape: Opioids in Pregnancy: What Raises the Risk for Neonatal Abstinence?
Micke
Did I do the math correctly? I calculated that the occurrence was 0.96%---Is that considered a rate that warrents AAP recommendations?
Prescription Opioid Epidemic and Infant Outcomes
Patrick SW, Dudley J, Martin PR, et al
Pediatrics. 2015;135:842-850
Opioid Exposure and Neonatal Abstinence
Coincident increases have been observed in prescriptions for oral opioids in pregnancy and in neonatal abstinence syndrome (NAS), characterized by a range of symptoms, from poor feeding, irritability, and hypertonicity, to other neurologic symptoms, such as seizures. This study used Tennessee Medicaid data and other vital records to assess maternal use of opioids and other drugs during the 30 days prior to delivery to determine whether opioid use patterns were associated with risk for NAS. Specifically, the researchers evaluated whether maternal cumulative opioid exposure, the type of opioid, tobacco smoke exposure, and use of selective serotonin reuptake inhibitors (SSRIs) were associated with NAS in the women's offspring.
Mothers aged 15-44 years who were enrolled in the Medicaid program and gave birth in 2009-2011 comprised the cohort. Using pharmacy claims, the study authors identified women who received short-acting opioids, long-acting opioids, maintenance opioids, and SSRIs. Birth certificates provided data on tobacco smoke exposure. Maternal data included age, education, number of births, race, hepatitis status, HIV status, and documentation of depression or anxiety. The researchers attempted to identify the reason for opioid use: acute pain, chronic pain, headache, or musculoskeletal diseases. Infants diagnosed with NAS were identified by International Statistical Classification of Disease–9 codes. The study authors also looked for the presence of such clinical signs as respiratory difficulties, feeding difficulties, seizures, sepsis, necrotizing enterocolitis, and other symptoms and clinical entities previously known to be associated with NAS.
Study Findings
There were more than 112,000 pregnant women in the cohort, 28% of whom had received at least one opioid prescription during pregnancy. Use of tobacco and receiving an SSRI were both more likely to occur in women who had received opioid prescriptions. The overwhelming majority of the opioid prescriptions (96.2%) were for short-acting medications. Only 2.7% received maintenance opioids, and 0.6% received a long-acting opioid. A total of 1086 infants were diagnosed with NAS, 65% of whom were born to mothers who had received at least one opioid prescription. Among infants exposed to maintenance opioids (eg, buprenorphine hydrochloride), 29.3% developed NAS. Of infants exposed to long-acting opioids, 14.7% developed NAS, compared with only 1.4% of those exposed to short-acting opioids.
Higher percentages of respiratory diagnoses, difficulties with eating, and seizures were found among infants with NAS compared with those who did not exhibit NAS. After adjusting for maternal factors, infant factors, and calendar year, the investigators found that cumulative exposure to short-acting opioids, any exposure to the longer-acting opioids, cigarette exposure, and the use of SSRIs within 30 days prior to delivery were all positively and independently associated with the likelihood of the infant developing NAS. The different independent associations were additive, such that the highest risk of developing NAS occurred among infants who were exposed to opioids for 25 weeks or longer, whose mothers smoked 20 cigarettes a day or more, and whose mothers were prescribed an SSRI. Of those infants, 36.6% developed NAS compared with 0.01% among infants exposed to short-acting opioids for up to 5 weeks but without tobacco or SSRIs.
The rate of NAS in the overall cohort almost doubled in a relatively short, 3-year period. The investigators concluded that the use of opioids in pregnancy is common and has strong associations with NAS. Patterns of opioid exposure as well as opioid type, with concomitant tobacco or SSRI exposure, increase the chance that an infant will develop NAS.
Viewpoint
The American Academy of Pediatrics[1] recommends observation for up to 4 days in an infant who exhibits NAS, but most nurseries use combinations of symptom scores and other measures of infant well-being to decide on the timing of discharge. The data about the additive risk of tobacco smoke or SSRIs are very interesting and can help clinicians identify populations to watch more carefully.
References
Hudak ML, Tan RC, The Committee on Drugs, The Committee on Fetus and Newborn. Neonatal drug withdrawal. Pediatrics. 2012;129:e540-e560. Abstract
Medscape Pediatrics © 2015 WebMD, LLC: http://www.medscape.com/viewarticle/849863?src=wnl_edit_tpal&uac=191482AT
William T. Basco, Jr., MD, MS
|August 24, 2015
Dionetta Hudzinski
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