Opioids Blamed for Spike in Withdrawal Cases in the NICU

Jim Kling

May 01, 2015

SAN DIEGO — The number of infants born with neonatal abstinence syndrome has mushroomed in recent years, according to the results of a new study, and more newborns are suffering from withdrawal symptoms from drugs they were exposed to in the womb.

"We feel strongly that this increase is closely tied to the epidemic of opioid pain reliever use," said Veeral Tolia, MD, from the Baylor University Medical Center in Dallas.

"When neonatal abstinence was first described, it was moms using heroin. In our sample, they were predominantly on opioid pain prescriptions or other medications to manage withdrawal symptoms," he told Medscape Medical News.

In fact, the increase in neonatal abstinence syndrome — from seven cases per 1000 infants in 2004 to 27 cases in 2013 (P < .001) — mirrors the opioid-use epidemic.

There has been a nearly four-fold increase in the number of painkillers prescribed and sold in the United States, despite no increase in reported pain, according to the Centers for Disease Control and Prevention. One study showed that 14.4% of women received opioids at least once during pregnancy (Anesthesiology. 2014;120:1216-1224).

Dr Tolia presented the research here at the Pediatric Academic Societies 2015 Annual Meeting, and the study was published online in the New England Journal of Medicine to coincide with the presentation.

A 2012 study chronicled the increase in neonatal abstinence syndrome rates from 2000 and 2009, but it relied on ICD-9 codes and provided no clinical details (JAMA. 2012;307:1934-1940).

For their study, Dr Tolia and his colleagues used de-identified information from MEDNAX, a national medical group that serves about 20% of babies in neonatal intensive care units (NICUs) in the United States.

The team looked at a number of aspects of treatment, including the length of stay in the NICU and whether the infant received medication.

Of the 674,845 infants admitted to NICUs from 2004 to 2013, the researchers identified 10,327 with neonatal abstinence syndrome. In addition to the increase in the incidence of the syndrome, there was a significant increase in NICU resources dedicated to the infants.

Table. Changes in the Treatment of Neonatal Abstinence Syndrome

Outcome 2004 2013 P Value
Median NICU stay, days 13 19 <.001
NICU days attributable to the syndrome, % 0.6 4.0 <.001
Infants treated with pharmacotherapy, % 74.0 87.0 <.001
Infants breast-fed during NICU stay, % 20.0 35.0 <.001


It is possible that, in the latter years of the study, physicians were more aware of the condition and therefore more likely to diagnose it, the researchers report.

However, if more cases were identified because of greater awareness, there would likely be increases in diagnoses in infants with more moderate symptoms and shorter hospital stays. Instead, the study showed trends toward longer hospital stays and increased rates of pharmacologic treatment, which suggest more severe symptoms.

"We want to alert both the public and healthcare providers of the risk of these medications, particularly in pregnant women. I don't think there's a lot of awareness of that," said Dr Tolia.

Treatment strategy is another concern. The American Academy of Pediatrics has issued guidelines for the treatment of newborns with neonatal abstinence syndrome, but the guidelines are somewhat vague and the suggested strategies haven't been vigorously tested, he said.

Keeping the baby in a low-stimulus environment and with the mother is one of the nonpharmacologic interventions. Another is breast-feeding, but that is often prevented because of concerns about the mother's previous drug use.

"There's a fair bit of evidence that breast-feeding is very beneficial, but there's still a hesitancy to let the mothers breast-feed or stay with their babies," said Dr Tolia. There was an increase in breast-feeding during the study period, from 20% in 2004 to 35% in 2013.

Results from this study confirm that there has been a substantial increase in the percentage of NICU days attributable to neonatal abstinence syndrome, which many have suspected, said session moderator Scott Lorch, MD, from the Children's Hospital of Philadelphia.

In 2004, the condition accounted for more than 10% of NICU patient-days in only one of the 157 (0.6%) centers involved in the study; in 2013, this increased to 23 of 213 centers (10.8%). And two centers reported rates in the range of 45% to 50%.

The care of these patients might be inefficient in some cases, Dr Lorch said. Hospitals have the choice of treating neonatal abstinence syndrome patients in the NICU or on the pediatric ward, and "many of these babies, at the end of the day, probably don't require ICU-level care," he told Medscape Medical News.

The variation in care underscores the importance of determining a standard of care for these patients. "There's a lot of variability in care that surrounds these infants. As the number of cases rises, that variation becomes more important," he added.

The study was funded internally. Dr Tolia and Dr Lorch have disclosed no relevant financial relationships.

Pediatric Academic Societies (PAS) 2015 Annual Meeting: Abstract 2760.1. Presented April 26, 2015.


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