An Examination of Feeding Practices and Outcomes of Newborns with Prenatal Exposure to Medication for Opioid Use Disorder in Pregnancy

Abstract

University of Minnesota Ph.D. dissertation. January 2026. Major: Nursing. Advisor: Jayne Fulkerson. 1 computer file (PDF); xiv, 166 pages.Purpose and Background/Significance: The benefits of breast milk for newborns are well understood, and especially important for newborns exposed to Medication for Opioid Disorder (MOUD), including methadone, buprenorphine, and buprenorphine-naloxone, in utero. In a recent systematic review, breast milk exposure decreased the severity of Neonatal Opioid Withdrawal Syndrome (NOWS) in newborns exposed to methadone MOUD by reducing the need for pharmacologic treatment and the length of hospital stay. However, less is known about the impact of other types of MOUD treatment, although MOUD treatment with buprenorphine has demonstrated some improved newborn outcomes. A new functional approach, the Eat Sleep Console model of care, promotes non-pharmacologic strategies first, such as encouraging parents to breastfeed after birth, prior to any pharmacologic interventions for newborns exposed to MOUD prenatally. However, breast milk as a feeding practice is still underutilized among women in MOUD treatment. Notably, researching the timing and continuity of breast milk exposure from the first feeding in the hospital after birth (first feed) to the plan for feeding post-discharge (at discharge) is warranted. The present study aimed to examine the incidence and continuity of feeding practices at first feed and at discharge among newborns with prenatal exposure to MOUD and examine how these feeding practices are associated with newborn outcomes. Methods: An observational retrospective secondary analysis was conducted of longitudinal electronic health record (EHR) data of maternal/newborn dyads (N=81) from a Midwest urban hospital from 2019-2023 with prenatal exposure to MOUD (methadone, buprenorphine, or buprenorphine-naloxone) to assess feeding practices (i.e., direct breastfeeding (DBF), direct breastfeeding and/or human milk feeding (HMF), formula and direct breastfeeding and/or human milk feeding, or formula only as well as any exposure to breast milk versus formula only) at first feed and at discharge. Associations between feeding practices and newborn outcomes (i.e., pharmacologic treatment, LOS, cost, newborn weight, and readmissions for NOWS) in relation to MOUD type were examined. Differences in demographics and newborn outcomes by feeding practices, and newborn outcomes by demographics were assessed using Chi-Square or Fisher’s Exact Tests. Any significant associations were further explored using multivariate logistic regression, unadjusted and adjusted for covariates relevant to the specific outcome (e.g., MOUD type, prescribed medications (selective serotonin reuptake inhibitors (SSRIs), gabapentin, and benzodiazepines), and non-prescribed substance (evidence of non-prescribed substance use by toxicology testing). Results: The majority of newborns (M=38.7 weeks) were male (62%) and appropriate size for gestational age (58%). About a quarter of newborns (22%) had significant NOWS requiring pharmacologic treatment, and more than one-quarter (27%) had weight loss ≥10%. The median length of stay (LOS) was 5 days. About half of the women (M=29.5 years old) identified as American Indian/Alaska Native (51%), and nearly two-thirds reported tobacco use (64%). Less than half tested positive for a non-prescribed substance (42%). In terms of MOUD treatment, methadone and buprenorphine were each prescribed in 35% of women, with buprenorphine-naloxone prescribed slightly less (31%). The most common feeding practices at first feed were DBF (47%) or Formula Only (47%), followed by Formula with DBF and/or HMF (4%) and DBF and HMF (2%). There was a significant positive association between feeding type at first feed and at discharge (p=.001). Of newborns DBF at first feed (47%), 32% were DBF or 16% were HMF at discharge. Of newborns who were fed Formula Only at first feed, 84% were fed this way at discharge. The odds of exposure to breast milk at discharge were 24 times higher if newborns were exposed to breast milk at first feed (p<.001). Newborns exposed to buprenorphine and buprenorphine-naloxone MOUD were significantly more likely to be DBF at discharge compared to methadone exposed newborns (χ²=9.57, p=.01). There were significant differences in receipt of pharmacologic treatment (FET, p=.02) and LOS (χ²=82.7, p=.04) by feeding practice at discharge. In the unadjusted model, the odds of receiving pharmacologic treatment were 79% lower (OR=0.21) for newborns with any breast milk exposure at discharge compared to those with being fed formula only (p=.01). In a series of models adjusting for covariates (MOUD type and prescribed medications) associations between any exposure to breast milk at discharge and pharmacologic treatment were essentially unchanged. However, in a model adjusting for testing positive for a non-prescribed substance and another including all covariates (i.e., MOUD type, prescribed medications, and non-prescribed substance) and the association between any exposure to breast milk discharge and pharmacologic treatment was no longer statistically significant. In the unadjusted model, the odds of a LOS eight days or more were 87% lower (OR=0.13) for newborns with any exposure to breast milk at discharge compared to those with formula only exposure (p<.01). In a series of models adjusting for all covariates, associations between any exposure to breast milk at discharge and LOS were essentially unchanged. There was no significant difference in newborn weight loss ≥ 10% (χ²=6.6, p=.91) by feeding practice at discharge. There was only one readmission due to NOWS in the sample; therefore, no analyses were conducted with this outcome. Conclusions: Overall, in a population of newborns with prenatal opioid exposure, the first feed in the hospital is critical for the promotion of breastfeeding, as it significantly impacts the likelihood of breast milk exposure at discharge. Type of MOUD is associated with feeding practice; therefore, providers prescribing methadone should be aware of potentially lower rates of DBF and an increased risk of newborns requiring pharmacologic treatment to treat symptoms of withdrawal. Additionally, in newborns exposed to MOUD, any breast milk exposure appeared to decrease the need for pharmacologic treatment and shorten the length of stay; however, this association was not statistically significant once adjustments were made for non-prescribed substance use. Thus, efforts to promote early initiation and exposure to breast milk should be promoted when appropriate, but may be complicated when other substances are used. Breastfeeding in this high-risk group of newborns was not associated with weight loss that appears to be any different than weight loss in the general population of healthy newborns. Due to the retrospective nature of these data, a more prospective, well-powered longitudinal study is warranted to replicate these findings. While these results are promising, evidence-based practice improvements post birth should also be aimed at reducing maternal bias and stigma associated with opioid use disorder. Providers should focus on conducting clear functional assessments of opioid exposed newborns with a primary focus on a non-pharmacologic approach to care first, such as ESC, before any treatment modality.Sommerness Reimer, Samantha. (2026). An Examination of Feeding Practices and Outcomes of Newborns with Prenatal Exposure to Medication for Opioid Use Disorder in Pregnancy. Retrieved from the University Digital Conservancy, https://hdl.handle.net/11299/279783