NRS-433V Evidence-Based Practice Literature Search
Evidence-Based Practice Literature Search
Backes, C. H., Backes, C. R., Gardner, D., Nankervis, C. A., Giannone, P. J., & Cordero, L. (2012). Neonatal abstinence syndrome: transitioning methadone-treated infants from an inpatient to an outpatient setting. Journal Of Perinatology, 32(6), 425-430. doi:10.1038/jp.2011.114
Objective: Each year in the US ∼50 000 neonates receive inpatient pharmacotherapy for the treatment of neonatal abstinence syndrome (NAS). The objective of this study is to compare the safety and efficacy of a traditional inpatient only approach with a combined inpatient and outpatient methadone treatment program. Study Design: Retrospective review (2007 to 2009). Infants were born to mothers maintained on methadone in an antenatal substance abuse program. All infants received methadone for NAS treatment as inpatient. Methadone weaning for the traditional group (75 patients) was inpatient, whereas the combined group (46 patients) was outpatient. Result: Infants in the traditional and combined groups were similar in demographics, obstetrical risk factors, birth weight, gestational age (GA) and the incidence of prematurity (34 and 31%). Hospital stay was shorter in the combined than in the traditional group (13 vs 25 days; P<0.01). Although the duration of treatment was longer for infants in the combined group (37 vs 21days, P<0.01), the cumulative methadone dose was similar (3.6 vs 3.1 mg kg−1, P=0.42). Follow-up information (at least 3 months) was available for 80% of infants in the traditional and 100% of infants in the combined group. All infants in the combined group were seen 72 h from hospital discharge. Breastfeeding was more common among infants in the combined group (24 vs 8% P<0.05). Following discharge there were no differences between the two groups in hospital readmissions for NAS. Prematurity (34 to 36 weeks GA) was the only predictor for hospital readmission for NAS in both groups (P=0.02, OR 5). Average hospital cost for each infant in the combined group was $13 817 less than in the traditional group. Conclusion: A combined inpatient and outpatient methadone treatment in the management of NAS decreases hospital stay and substantially reduces cost NRS-433V Evidence-Based Practice Literature Search. Additional studies are needed to evaluate the potential long-term benefits of the combined approach on infants and their families.
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Cleary, B., Donnelly, J., Strawbridge, J., Gallagher, P., Fahey, T., Clarke, M., & Murphy, D. (2010). Methadone dose and neonatal abstinence syndrome-systematic review and meta-analysis. Addiction, 105(12), 2071-2084. doi:10.1111/j.1360-0443.2010.03120.x
Aim To determine if there is a relationship between maternal methadone doses in pregnancy and the diagnosis or medical treatment of neonatal abstinence syndrome (NAS). Methods PubMed, EMBASE, the Cochrane Library and PsychINFO were searched for studies reporting on methadone use in pregnancy and NAS (1966-2009). The relative risk (RR) of NAS was compared for methadone doses above versus below a range of cut-off points. Summary RRs and 95% confidence intervals (CI) were estimated using random effects meta-analysis. Sensitivity analyses explored the impact of limiting meta-analyses to prospective studies or studies using an objective scoring system to diagnose NAS. Results A total of 67 studies met inclusion criteria for the systematic review; 29 were included in the meta-analysis. Any differences in the incidence of NAS in infants of women on higher compared with lower doses were statistically non-significant in analyses restricted to prospective studies or to those using an objective scoring system to diagnose NAS. Conclusions Severity of the neonatal abstinence syndrome does not appear to differ according to whether mothers are on high- or low-dose methadone maintenance therapy. NRS-433V Evidence-Based Practice Literature Search.
Kaltenbach, K., Holbrook, A. M., Coyle, M. G., Heil, S. H., Salisbury, A. L., Stine, S. M., & … Jones, H. E. (2012). Predicting treatment for neonatal abstinence syndrome in infants born to women maintained on opioid agonist medication. Addiction, 45-52. doi:10.1111/j.1360-0443.2012.04038.x
Aim To identify factors that predict the expression of neonatal abstinence syndrome ( NAS) in infants exposed to methadone or buprenorphine in utero. Design and Setting Multi-site randomized clinical trial in which infants were observed for a minimum of 10 days following birth, and assessed for NAS symptoms by trained raters. Participants A total of 131 infants born to opioid dependent mothers, 129 of whom were available for NAS assessment. Measurements Generalized linear modeling was performed using maternal and infant characteristics to predict: peak NAS score prior to treatment, whether an infant required NAS treatment, length of NAS treatment and total dose of morphine required for treatment of NAS symptoms. Findings Of the sample, 53% (68 infants) required treatment for NAS. Lower maternal weight at delivery, later estimated gestational age ( EGA), maternal use of selective serotonin re-uptake inhibitors ( SSRIs), vaginal delivery and higher infant birthweight predicted higher peak NAS scores NRS-433V Evidence-Based Practice Literature Search. Higher infant birthweight and greater maternal nicotine use at delivery predicted receipt of NAS treatment for infants. Maternal use of SSRIs, higher nicotine use and fewer days of study medication received also predicted total dose of medication required to treat NAS symptoms. No variables predicted length of treatment for NAS. Conclusions Maternal weight at delivery, estimated gestational age, infant birthweight, delivery type, maternal nicotine use and days of maternal study medication received and the use of psychotropic medications in pregnancy may play a role in the expression of neonatal abstinence syndrome severity in infants exposed to either methadone or buprenorphine.
MacMullen, N. J., Dulsk, L. A., & Blobaum, P. (2014). Evidence-Based Interventions For Neonatal Abstinence Syndrome. Pediatric Nursing, 40(4), 165-203.
This review aimed to determine best nursing practice by systematically and critically reviewing the appropriate literature and expert guidelines. Using keywords and literature databases, over 480 journal titles were reviewed. Twenty-four articles and three expert guidelines were chosen. The majority of articles selected as evidence were Level IV – opinions of respected authorities based on clinical experiences, descriptive studies, case reports, or reports of experts. Two articles were Level I-II – experimental studies. Results of the review showed that traditional supportive interventions also have a body of evidence for their use. Although there is much research regarding neonatal abstinence syndrome (NAS), the majority of future research needs to be at a higher level of evidence. Nursing applications include obtaining evidence for best practice through diligent searches of the literature and expert guidelines. NRS-433V Evidence-Based Practice Literature Search.
Patrick, S. W., Kaplan, H. C., Passarella, M., Davis, M. M., & Lorch, S. A. (2014). Variation in treatment of neonatal abstinence syndrome in US Children’s Hospitals, 2004-2011. Journal Of Perinatology, 34(11), 867-872. doi:10.1038/jp.2014.114
Objective: Neonatal abstinence syndrome (NAS) is a drug withdrawal syndrome experienced by opioid-exposed infants. There is no standard treatment for NAS and surveys suggest wide variation in pharmacotherapy for NAS. Our objective was to determine whether different pharmacotherapies for NAS are associated with differences in outcomes and to determine whether pharmacotherapy and outcome vary by hospital. Study Design: We used the Pediatric Health Information System Database from 2004 to 2011 to identify a cohort of infants with NAS requiring pharmacotherapy. Mixed effects hierarchical negative binomial models evaluated the association between pharmacotherapy and hospital with length of stay (LOS), length of treatment (LOT) and hospital charges, after adjusting for socioeconomic variables and comorbid clinical conditions.Result:Our cohort included 1424 infants with NAS from 14 children’s hospitals. Among hospitals in our sample, six used morphine, six used methadone and two used phenobarbital as primary initial treatment for NAS. In multivariate analysis, when compared with NAS patients initially treated with morphine, infants treated with methadone had shorter LOT (incidence rate ratio (IRR)=0.55; P<0.0001) and LOS (IRR=0.60; P<0.0001). Phenobarbital as a second-line agent was associated with increased LOT (IRR=2.09; P<0.0001), LOS (IRR=1.78; P<0.0001) and higher hospital charges (IRR=1.84; P<0.0001). After controlling for case-mix, hospitals varied in LOT, LOS and hospital charges. Conclusion: We found variation in hospital in treatment for NAS among major US children’s hospitals. In analyses controlling for possible confounders, methadone as initial treatment was associated with reduced LOT and hospital stay NRS-433V Evidence-Based Practice Literature Search.
Sarkar, S., & Donn, S. (2006). Management of neonatal abstinence syndrome in neonatal intensive care units: a national survey. Journal Of Perinatology, 26(1), 15-17.
Aims: To determine the monitoring and treatment of neonatal abstinence syndrome (NAS) in neonatal intensive care units (NICUs) following opiate or polydrug exposure in utero. Methods: A pretested questionnaire was distributed via email to the chiefs of the neonatology divisions with accredited Fellowship programs in Neonatal-Perinatal Medicine in the United States. Results: Of the 102 individuals contacted, 75 participated in the survey. In all, 41 of the respondents (54.5%) have a written policy regarding the management of neonatal NAS. The method of Finnegan is the most commonly used abstinence scoring system (49 of 75, 65%), while only three respondents use the Lipsitz tool. Opioids (tincture of opium, or morphine sulfate solution) are used most commonly for management of both opioid (63% of respondents) and polydrug (52% of respondents) withdrawal, followed by phenobarbital (32% of respondents) for polydrug withdrawal and methadone (20% of respondents) for opioid withdrawal. In all, 53 respondents (70%) use phenobarbital, and 19 (25%) use intravenous morphine to control opioid withdrawal seizures, while 61 (81%) use phenobarbital in cases of polydrug withdrawal seizures. Only 53 respondents (70%) always use an abstinence scoring system to determine when to start, titrate, or terminate pharmacologic treatment of neonatal NAS. Conclusion: The management of neonatal psychomotor behavior consistent with withdrawal varies widely, with inconsistent policies to determine its presence or treatment. Only about half of NICUs have written guidelines for the management of NAS, which may preclude effective auditing of this practice. Educational interventions may be necessary to ensure changes in clinical practice. Journal of Perinatology (2006) 26, 15-17. doi:10.1038/sj.jp.7211427; published online 24 November 2005 NRS-433V Evidence-Based Practice Literature Search