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opioids

Pediatric Pearls: Caring for Infants With Intrauterine Opioid Exposure

The mother of a 28-month-old girl with a history of intrauterine opioid exposure brings the infant in with concerns of a low fever. While examining the patient's records, you realize that the infant has not been had a well visit in over a year.

How would you advise your patient?

(Answer and discussion on next page)

Jordan N. Watson, MD, FAAP, is clinical assistant professor of pediatrics at the Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, Pennsylvania. She is a general pediatrician and the medical director of the Dermatology Access Clinic in the Division of General Pediatrics at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Delaware.

The opioid epidemic continues to heighten, affecting an increasing number of children. From 1999 to 2014, the rate of opioid use disorder in pregnancy increased by more than 400% in the United States.1 In 2014, an infant was born with neonatal abstinence syndrome (NAS) every 15 minutes in the United States.2 As a primary care provider, it is important to be familiar with the unique challenges, including physical, mental, and psychosocial, these infants and their families may encounter. In addition to the physical consequences affecting the neonatal period, research has shown that infants with intrauterine opioid exposure may face additional challenges that can affect them over their lifespan. A study in Pediatrics from 2015 linked NAS with an increased risk of educational disabilities.3 Other recent evidence suggests that children with intrauterine opioid exposure may have impaired cognitive, psychomotor, and observed behavioral outcomes when compared with their nonopioid exposed peers.4 Behavioral and neurodevelopment concerns are often first noticed at well-child care visits with the primary care provider. A new study in Pediatrics examines the adherence to well-child care visits in children with intrauterine opioid exposure in the first 2 years of life.5

The Research

This new retrospective cohort study included 11,334 children from 3 states within a pediatric primary care network. Using the PEDSnet database, the researchers included data from children born between 2011 and 2016 who had had a primary care visit within 90 days of life. Children were excluded if they had no primary care visit after their first birthday. The study cohort (2.1% of the sample) included all children with a diagnosis of intrauterine opioid exposure, regardless of treatment for NAS—though the majority (80.1%) had NAS.

The children with intrauterine opioid exposure had a lower average birth rate, were more likely to live in higher-poverty areas, were more likely to be white, and were more likely to be insured by Medicaid, compared with those without intrauterine opioid exposure. There were no differences observed between the 2 study groups in gestational age, diagnosis of complex chronic conditions, sex, or metropolitan residence. The primary outcome of the study was adherence to well-child care based on American Academy of Pediatrics recommendations. This was defined in the first year as a completed postnatal or 1-month visit and completed 2-, 4-, 6-, 9-, and 12-month visits; and in the second year as completing 15- and 18-month visits. A gap in well-child care was considered missing greater than 2 consecutive well-child care visits. Secondary outcomes included immunization status by 2 years of life, nonroutine visits in the first 2 years of life, and lead level screening at 1 year.

The Results

The researchers found a statistically significant difference in well-child care adherence between children with and without intrauterine opioid exposure. In the first year, children with intrauterine opioid exposure had a 25.9% adherence to well-child care, compared with 54.7% among their peers without intrauterine opioid exposure. In the second year, children with intrauterine opioid exposure had a 41.5% adherence to well-child care, compared with 57.5% among their peers without intrauterine opioid exposure.

Children with intrauterine opioid exposure also had an increased likelihood to have a gap in well-child care in the first 2 years of life. There were no statistically significant differences in secondary outcomes (immunization status by 2 years of life, nonroutine visits in the first 2 years of life, and lead level screening at 1 year) between the 2 groups. The authors suggest that children with intrauterine opioid exposure may be “catching up” with some components of well-child care, including immunizations at nonroutine visits. A major limitation to the study noted by the authors included relying on billing codes for indication of opioid exposure, which may underestimate infants without NAS with intrauterine opioid exposure and limit insight on severity or type of opioid exposure.

Bottom Line—Children with intrauterine opioid exposure and their families may need additional social, physical, developmental, and mental health support, and with an greater risk of decreased adherence to well-child care, this should be identified and considered in their medical home.

Disclosure: All of the authors of this article currently practice at the same institution as Jordan Watson; Jessica F. Rhode, MD, is one of her colleagues in the Division of General Pediatrics. However, Dr Watson did not receive any incentive or funding for writing this summary article.

 

References:

  1. Haight SC, Ko JY, Tong VT, Bohm MK, Callaghan WM. Opioid use disorder documented at delivery hospitalization — United States, 1999-2014. MMWR Morb Mortal Wkly Rep. 2018;67(31):845-849. https://doi.org/10.15585/mmwr.mm6731a1.
  2. Jilani SM, Frey MT, Pepin D, et al. Evaluation of state-mandated reporting of neonatal abstinence syndrome — six states, 2013-2017. MMWR Morb Mortal Wkly Rep. 2019;68(1):6-10. https://doi.org/10.15585/mmwr.mm6801a2.
  3. Fill MMA, Miller AM, Wilkinson RH, et al. Educational disabilities among children born with neonatal abstinence syndrome. Pediatrics. 2018;142(3):e20180562. https://doi.org/10.1542/peds.2018-0562.
  4. Baldacchino A, Arbuckle K, Petrie DJ, McCowan C. Erratum: neurobehavioral consequences of chronic intrauterine opioid exposure in infants and preschool children: a systematic review and meta-analysis. BMC Psychiatry. 2015;15:134. https://doi.org/10.1186/s12888-015-0438-5.
  5. Goyal NK, Rohde JF, Short V, Patrick SW, Abatemarco D, Chung EK. Well-child care adherence after intrauterine opioid exposure. Pediatrics. 2020;145(2):e20191275. https://doi.org/10.1542/peds.2019-1275.