Predictors of Neonatal Abstinence Syndrome in Buprenorphine Exposed Newborn: Can Cord Blood Buprenorphine Metabolite Levels Help?

Background Buprenorphine is a semi-synthetic opioid used for the treatment of opioid dependence. Opioid use, including buprenorphine, has been increasing in recent years, in the general population and in pregnant women. Consequently, there has been a rise in frequency of neonatal abstinence syndrome (NAS), associated with buprenorphine use during pregnancy. The purpose of this study was to investigate correlations between buprenorphine and buprenorphine-metabolite concentrations in cord blood and onset of NAS in buprenorphine exposed newborns. Methods Nineteen (19) newborns who met inclusion criteria were followed after birth until discharge in a double-blind non-intervention study, after maternal consent. Cord blood and tissue samples were collected and analyzed by liquid chromatography–mass spectrometry (LC–MS) for buprenorphine and metabolites. Simple and multiple logistic regressions were used to examine relationships between buprenorphine and buprenorphine metabolite concentrations in cord blood and onset of NAS, need for morphine therapy, and length of stay. Results Each increase in 5 ng/ml level of norbuprenorphine in cord blood increases odds of requiring treatment by morphine 2.5 times. Each increase in 5 ng/ml of buprenorphine-glucuronide decreases odds of receiving morphine by 57.7 %. Along with concentration of buprenorphine metabolites, birth weight and gestational age also play important roles, but not maternal buprenorphine dose. Conclusions LC–MS analysis of cord blood concentrations of buprenorphine and metabolites is an effective way to examine drug and metabolite levels in the infant at birth. Cord blood concentrations of the active norbuprenorphine metabolite and the inactive buprenorphine-glucuronide metabolite show promise in predicting necessity of treatment of NAS. These finding have implications in improving patient care and reducing healthcare costs if confirmed in a larger sample

Correlation of Newborn’s Clinical Course with Cord Blood Levels of Buprenorphine, Methadone, and Their Metabolites

Purpose In recent years, there has been a significant increase in opioid-related drug use among pregnant mothers, specifically Methadone, Subutex (Buprenorphine) and Suboxone (Buprenorphine and Naloxone) resulting in increased neonatal intensive care unit (NICU) admissions for treatment of neonatal abstinence syndrome (NAS). Standard tests such as urine, meconium, and cord stat blood samples have not been shown to accurately demonstrate maternal abuse of these medications or predict the clinical course of NAS. This study aims to correlate and compare clinical symptoms of NAS with cord/ placental blood concentrations of Buprenorphine, Methadone and their metabolites. Another goal is to demonstrate the ability to correctly identify maternal abuse and concentrations of these medications. Methods The design was an observational study where cord/placental blood samples were obtained from eligible subjects. In addition to the standard cord stat test done by state, samples were analyzed using liquid chromatography mass spectrometry (LC-MS/MS) to quantify the metabolites of Buprenorphine, Norbuprenorphine and Methadone. Investigators performing the LC-MS/MS were blinded. Infants were treated on attending physician’s discretion according to clinical course. All infants were followed until discharge. Demographics and clinical course, including NICU stay, were recorded. Results A total of 19 mothers were enrolled, out of which, 15 (78.9%) mothers were on Subutex, 2 (10.5%) on Suboxone and 2 (10.5%) on Methadone. Data analysis was performed only on subjects with exposure to Subutex due to low sample size for Suboxone and Methadone subjects. Cord stat performed by the state lab was negative in 33.3% of subjects; however, 100% of the cord blood samples tested by LC-/MSMS were positive. The percentage of neonates transferred to NICU for NAS was 60% of which 67% received replacement therapy. Length of stay in NICU for treatment of NAS did not have any correlation to the concentration of the metabolites in cord blood. Pearson’s correlation coefficient (r) between duration of NICU stay and Norbuprenorhine concentration was r = -0.07 (p-value = 0.40); Buprenorphine concentration was r = -0.30 (p-value = 0.14); Norbuprenorphine-glucoronate concentration was r = -0.05 (p-value = 0.43); Buprenorphine-glucoronate concentration was r = -0.31 (p-value = 0.13). No correlation was found after adding the concentrations of all the above metabolites with NICU stay r = -0.24 (p-value = 0.19). Conclusion The cord stat result is inferior to cord/placental blood levels of drug metabolites using LC-MS/MS for diagnosing maternal substance abuse in at risk infants. No correlation was found between the concentrations of metabolites and length of stay in NICU or duration of replacement therapy. This study was limited by a small sample size

Community Partnerships to Promote Healthy Active Living: ReadNPlay for a Bright Future

Purpose To describe outcomes of community partnerships for promoting healthy active living among families with young children in the ReadNPlay for a Bright Future Project. Methods ReadNPlay for a Bright Future was developed through grant support from the American Academy of Pediatrics (AAP) and Metlife Foundation awarded to the East Tennessee State University Department of Pediatrics and Tennessee AAP Chapter. ReadNPlay is a coordinated, multi-level, multi-component initiative promoting healthy active living among families with young children during infant-toddler health supervision visits and in childcare and other community settings. The project site is located in rural southern Appalachia, an area of the country with a high prevalence of obesity. Materials and messages developed by the project team were finalized during a community forum with stakeholders held in Northeast Tennessee in fall 2012. Four themes emerged as a focus for the initiative: Play More: Shut off the Screen, Play Together: Be Active as a Family, Fuel to Play: Eat Healthy, and Play Safely. Partnerships with the regional children\u27s hospital, childcare providers, health department, public libraries, and farmers\u27 markets were supported through on-going communication via email, social media, and individual meetings. Availability of two $750 pediatric resident mini-grants and structure afforded by the residency program\u27s existing community pediatrics rotation facilitated development and implementation of community initiatives for this project. Results Project posters displayed in community settings, use of social media, and periodic community events are reinforcing efforts to promote healthy active living in the clinical setting. A new event for families with infants/toddlers was added to the children\u27s hospital annual Kids Run, involving over 120 families during the first year. Walk N\u27 Rollers received free Reach Out and Read books and were surprised at the sugar content of juice and other beverages displayed in sippy cups as part of a “Sugar Quiz.” Information disseminated through regional child care centers will promote participation in a summer Walk N\u27 Roll program in addition to this annual event. At a regional childcare provider conference, ReadNPlay workshops with over 100 infant-toddler teachers and 40 families were conducted and information on Tennessee\u27s “Gold Sneaker” designation for compliance with state nutrition and physical activity policies was shared (only 6$10 farmers\u27 market vouchers at their 12-15 month well child visit to encourage consumption of fruits and vegetables. 18-month statistics on social media reach, walking program participation, new Gold Sneaker designations, and farmers\u27 market program participation will be presented. Conclusion This presentation will illustrate how pediatric residency programs and practitioners may partner with existing community organizations and initiatives to promote healthy active living in families with young children

Community Partnerships to Promote Healthy Active Living

Purpose To describe outcomes of community partnerships for promoting healthy active living among families with young children in the ReadNPlay for a Bright Future Project. Methods ReadNPlay for a Bright Future was developed through grant support from the American Academy of Pediatrics (AAP) and Metlife Foundation awarded to the East Tennessee State University Department of Pediatrics and Tennessee AAP Chapter. ReadNPlay is a coordinated, multi-level, multi-component initiative promoting healthy active living among families with young children during infant-toddler health supervision visits and in childcare and other community settings. The project site is located in rural southern Appalachia, an area of the country with a high prevalence of obesity. Materials and messages developed by the project team were finalized during a community forum with stakeholders held in Northeast Tennessee in fall 2012. Four themes emerged as a focus for the initiative: Play More: Shut off the Screen, Play Together: Be Active as a Family, Fuel to Play: Eat Healthy, and Play Safely. Partnerships with the regional children\u27s hospital, childcare providers, health department, public libraries, and farmers\u27 markets were supported through on-going communication via email, social media, and individual meetings. Availability of two $750 pediatric resident mini-grants and structure afforded by the residency program\u27s existing community pediatrics rotation facilitated development and implementation of community initiatives for this project. Results Project posters displayed in community settings, use of social media, and periodic community events are reinforcing efforts to promote healthy active living in the clinical setting. A new event for families with infants/toddlers was added to the children\u27s hospital annual Kids Run, involving over 120 families during the first year. Walk N\u27 Rollers received free Reach Out and Read books and were surprised at the sugar content of juice and other beverages displayed in sippy cups as part of a “Sugar Quiz.” Information disseminated through regional child care centers will promote participation in a summer Walk N\u27 Roll program in addition to this annual event. At a regional childcare provider conference, ReadNPlay workshops with over 100 infant-toddler teachers and 40 families were conducted and information on Tennessee\u27s “Gold Sneaker” designation for compliance with state nutrition and physical activity policies was shared (only 6$10 farmers\u27 market vouchers at their 12-15 month well child visit to encourage consumption of fruits and vegetables. 18-month statistics on social media reach, walking program participation, new Gold Sneaker designations, and farmers\u27 market program participation will be presented. Conclusion This presentation will illustrate how pediatric residency programs and practitioners may partner with existing community organizations and initiatives to promote healthy active living in families with young children

Promoting Healthy Active Living From Birth with ReadNPlay for a Bright Future

Purpose To describe: (1) development of ReadNPlay for a Bright Future with community stakeholders, (2) integration of a novel communicative tool, the ReadNPlay Baby Book, into infant-toddler well child visits, and (3) use of a quality improvement approach to monitor progress in promoting healthy active living in families with young children. Methods ReadNPlay for a Bright Future is funded by a grant from the American Academy of Pediatrics (AAP) and Metlife Foundation awarded to the East Tennessee State University Department of Pediatrics and Tennessee Chapter of the AAP. The setting for this project is in rural southern Appalachia, a U.S. region with a disproportionately high prevalence of obesity. During a community forum held in Northeast Tennessee in fall 2012, community stakeholders provided feedback to help finalize project materials and messages developed by the project team around four themes: Play More: Shut off the Screen, Play Together: Be Active as a Family, Fuel to Play: Eat Healthy, and Play Safely. A behavioral health consultant (BHC) assisted with provider training in brief motivational interviewing and behavioral counseling and project implementation in the clinic. An anonymous mothers\u27 survey was designed to identify opportunities for improving behaviors and monitor progress in promoting healthy active living during well child visits. Process measures and feedback will be obtained from provider surveys and focus groups with parents and providers. Results As of February 2013, the ReadNPlay Baby Book is being provided to families starting at the newborn visit. The book contains age-appropriate guidance and areas for parents to record their baby\u27s growth, milestones, eating habits, favorite books, and activities between birth and 18 months. Families are receiving small incentives for bringing it to each well child visit. A companion Healthy Active Living Tips booklet encourages healthy behaviors in the whole family. Use of social media, posters, and periodic community events provide reinforcement. A total of 80 mothers with infants 9-24 months of age are completing anonymous surveys during well child visits every 4-6 months (mostly Caucasian, 70% WIC recipients). Baseline surveys with mothers of younger infants (9-12 months of age) suggest: 60% of mothers are reading or looking at books with their infants on most days of the week; 80% of infants watch at least 30 minutes of television and 48.7% drink juice on a typical day; 82% of infants were ever-breastfed; 20% of mothers had sought care for their infants due to an injury; and 13.2% of infants routinely bed-share. Over 80% of all mothers wished that they themselves could get more exercise. Conclusion ReadNPlay for a Bright Future is using novel communication tools, community partnerships, and quality improvement methodology to encourage healthy active living during infant-toddler well child visit

Community Partnerships to Promote Healthy Active Living: ReadNPlay for a Bright Future

Purpose To describe outcomes of community partnerships for promoting healthy active living among families with young children in the ReadNPlay for a Bright Future Project. Methods ReadNPlay for a Bright Future was developed through grant support from the American Academy of Pediatrics (AAP) and Metlife Foundation awarded to the East Tennessee State University Department of Pediatrics and Tennessee AAP Chapter. ReadNPlay is a coordinated, multi-level, multi-component initiative promoting healthy active living among families with young children during infant-toddler health supervision visits and in childcare and other community settings. The project site is located in rural southern Appalachia, an area of the country with a high prevalence of obesity. Materials and messages developed by the project team were finalized during a community forum with stakeholders held in Northeast Tennessee in fall 2012. Four themes emerged as a focus for the initiative: Play More: Shut off the Screen, Play Together: Be Active as a Family, Fuel to Play: Eat Healthy, and Play Safely. Partnerships with the regional children\u27s hospital, childcare providers, health department, public libraries, and farmers\u27 markets were supported through on-going communication via email, social media, and individual meetings. Availability of two $750 pediatric resident mini-grants and structure afforded by the residency program\u27s existing community pediatrics rotation facilitated development and implementation of community initiatives for this project. Results Project posters displayed in community settings, use of social media, and periodic community events are reinforcing efforts to promote healthy active living in the clinical setting. A new event for families with infants/toddlers was added to the children\u27s hospital annual Kids Run, involving over 120 families during the first year. Walk N\u27 Rollers received free Reach Out and Read books and were surprised at the sugar content of juice and other beverages displayed in sippy cups as part of a “Sugar Quiz.” Information disseminated through regional child care centers will promote participation in a summer Walk N\u27 Roll program in addition to this annual event. At a regional childcare provider conference, ReadNPlay workshops with over 100 infant-toddler teachers and 40 families were conducted and information on Tennessee\u27s “Gold Sneaker” designation for compliance with state nutrition and physical activity policies was shared (only 6$10 farmers\u27 market vouchers at their 12-15 month well child visit to encourage consumption of fruits and vegetables. 18-month statistics on social media reach, walking program participation, new Gold Sneaker designations, and farmers\u27 market program participation will be presented. Conclusion This presentation will illustrate how pediatric residency programs and practitioners may partner with existing community organizations and initiatives to promote healthy active living in families with young children

Promoting Healthy Active Living From Birth with ReadNPlay for a Bright Future

Purpose To describe: (1) development of ReadNPlay for a Bright Future with community stakeholders, (2) integration of a novel communicative tool, the ReadNPlay Baby Book, into infant-toddler well child visits, and (3) use of a quality improvement approach to monitor progress in promoting healthy active living in families with young children. Methods ReadNPlay for a Bright Future is funded by a grant from the American Academy of Pediatrics (AAP) and Metlife Foundation awarded to the East Tennessee State University Department of Pediatrics and Tennessee Chapter of the AAP. The setting for this project is in rural southern Appalachia, a U.S. region with a disproportionately high prevalence of obesity. During a community forum held in Northeast Tennessee in fall 2012, community stakeholders provided feedback to help finalize project materials and messages developed by the project team around four themes: Play More: Shut off the Screen, Play Together: Be Active as a Family, Fuel to Play: Eat Healthy, and Play Safely. A behavioral health consultant (BHC) assisted with provider training in brief motivational interviewing and behavioral counseling and project implementation in the clinic. An anonymous mothers\u27 survey was designed to identify opportunities for improving behaviors and monitor progress in promoting healthy active living during well child visits. Process measures and feedback will be obtained from provider surveys and focus groups with parents and providers. Results As of February 2013, the ReadNPlay Baby Book is being provided to families starting at the newborn visit. The book contains age-appropriate guidance and areas for parents to record their baby\u27s growth, milestones, eating habits, favorite books, and activities between birth and 18 months. Families are receiving small incentives for bringing it to each well child visit. A companion Healthy Active Living Tips booklet encourages healthy behaviors in the whole family. Use of social media, posters, and periodic community events provide reinforcement. A total of 80 mothers with infants 9-24 months of age are completing anonymous surveys during well child visits every 4-6 months (mostly Caucasian, 70% WIC recipients). Baseline surveys with mothers of younger infants (9-12 months of age) suggest: 60% of mothers are reading or looking at books with their infants on most days of the week; 80% of infants watch at least 30 minutes of television and 48.7% drink juice on a typical day; 82% of infants were ever-breastfed; 20% of mothers had sought care for their infants due to an injury; and 13.2% of infants routinely bed-share. Over 80% of all mothers wished that they themselves could get more exercise. Conclusion ReadNPlay for a Bright Future is using novel communication tools, community partnerships, and quality improvement methodology to encourage healthy active living during infant-toddler well child visit

Promoting Healthy Active Living From Birth with ReadNPlay for a Bright Future

Purpose To describe: (1) development of ReadNPlay for a Bright Future with community stakeholders, (2) integration of a novel communicative tool, the ReadNPlay Baby Book, into infant-toddler well child visits, and (3) use of a quality improvement approach to monitor progress in promoting healthy active living in families with young children. Methods ReadNPlay for a Bright Future is funded by a grant from the American Academy of Pediatrics (AAP) and Metlife Foundation awarded to the East Tennessee State University Department of Pediatrics and Tennessee Chapter of the AAP. The setting for this project is in rural southern Appalachia, a U.S. region with a disproportionately high prevalence of obesity. During a community forum held in Northeast Tennessee in fall 2012, community stakeholders provided feedback to help finalize project materials and messages developed by the project team around four themes: Play More: Shut off the Screen, Play Together: Be Active as a Family, Fuel to Play: Eat Healthy, and Play Safely. A behavioral health consultant (BHC) assisted with provider training in brief motivational interviewing and behavioral counseling and project implementation in the clinic. An anonymous mothers’ survey was designed to identify opportunities for improving behaviors and monitor progress in promoting healthy active living during well child visits. Process measures and feedback will be obtained from provider surveys and focus groups with parents and providers. Results As of February 2013, the ReadNPlay Baby Book is being provided to families starting at the newborn visit. The book contains age-appropriate guidance and areas for parents to record their baby’s growth, milestones, eating habits, favorite books, and activities between birth and 18 months. Families are receiving small incentives for bringing it to each well child visit. A companion Healthy Active Living Tips booklet encourages healthy behaviors in the whole family. Use of social media, posters, and periodic community events provide reinforcement. A total of 80 mothers with infants 9-24 months of age are completing anonymous surveys during well child visits every 4-6 months (mostly Caucasian, 70% WIC recipients). Baseline surveys with mothers of younger infants (9-12 months of age) suggest: 60% of mothers are reading or looking at books with their infants on most days of the week; 80% of infants watch at least 30 minutes of television and 48.7% drink juice on a typical day; 82% of infants were ever-breastfed; 20% of mothers had sought care for their infants due to an injury; and 13.2% of infants routinely bed-share. Over 80% of all mothers wished that they themselves could get more exercise. Conclusion ReadNPlay for a Bright Future is using novel communication tools, community partnerships, and quality improvement methodology to encourage healthy active living during infant-toddler well child visits