Systematic mixed?study review of nonpharmacological management of neonatal abstinence syndrome

Background: Neonatal abstinence syndrome is a multi-system disorder resulting from exposure to maternal addictive substance use in pregnancy. Withdrawal is characterized by neonatal tremors, feeding difficulties and sleep disruption. The aim of this systematic review is to explore the non-pharmacological management of infants at risk of neonatal abstinence syndrome following prenatal exposure. Methods: A systematic mixed study review was conducted. A search of CINAHL, MEDLINE, AMED, PsycArticles, PsycInfo and Web of Science was performed for relevant articles published between January 2007 and June 2018. Quantitative and qualitative data were extracted, and thematic analysis undertaken. The findings were synthesized as a narrative summary. Results: Fourteen studies were included in the review of which nine were quality improvement initiatives and five explored complementary therapies. The most common components of non-pharmacological management were consolation therapy and rooming-in of mother and baby. Implementation strategies incorporated family integrated care and practitioner training in the evaluation of neonatal withdrawal. When non- pharmacological management was applied there was a reduction in the need for pharmacotherapy and a shorter hospital stay for neonates. Potential barriers to effective management included unreliable assessment tools, judgemental practitioner attitudes and limited breastfeeding promotion. Conclusion: Providing and optimizing non-pharmacological management for the infant at risk of neonatal abstinence syndrome improves outcomes by reducing their length of hospital stay and the need for pharmacotherapy

Construction of the Sophia Observation withdrawal Symptoms-scale (SOS) for critically ill children

Objective: To construct a reliable and clinically practical instrument for monitoring opioids and benzodiazepine withdrawal symptoms in pediatric ICU patients. Design: Instrument development. Setting: Intensive care unit in an academic children's hospital. Patients and participants: 79 patients up to age 16 years on intravenous midazolam and/or opioids for ≥5 days. An expert panel of 85 physicians and nurses rated clinical relevance of withdrawal symptoms. Intervention: During drug weaning repeated observations were performed with a checklist of 24 withdrawal symptoms described in the literature. Measurements and results: For 76 children, 932 observations were obtained within 24 h after decrease and/or discontinuation of midazolam or opioids. Most frequent symptoms were tachypnea, agitation, motor disturbance, diarrhea, fever, anxiety, sleep disturbance and hypertension (14.6-29.6%). Multidimensional scaling (MDS) was performed to detect the underlying empirical structure of co-occurrences of symptoms. An expert panel judged clinical relevance of each withdrawal symptom on a four-point scale ranging from 'definitively so' to 'definitively not'. Agitation, an

The wellbeing of infants exposed to Buprenorphine via breast milk at 4 weeks of age

Background: Buprenorphine has been available in Australia since 2000 as an alternative pharmacotherapy to methadone for the treatment of opioid dependence. However, there is little information in the literature regarding the effect of buprenorphine on the wellbeing of infants exposed to buprenorphine via breast milk, following discharge from hospital. Objective: The aim of the present study was to examine the wellbeing of infants exposed to buprenorphine via breast milk up to 4 weeks postnatal. Methods: Approximately 4 weeks after birth, information on the feeding and sleeping patterns, skin color, infant elimination patterns and hydration, and Neonatal Abstinence Scores of infants (n = 7) exposed to buprenorphine via breast milk was collected via both observation and documentation. Results: Infants were progressing well, with normal sleep patterns and skin color, and 2 mothers had minor concerns regarding infant elimination patterns. Four infants were exclusively breastfed and 3 were receiving a supplement, with a range of 260 to 700 mL of formula over 24 hours. The sleep patterns following feeding ranged from 1.55 to 3.33 hours, with a median of 2.12 hours. Conclusion: No adverse effects were detected in infants exposed to buprenorphine via breast milk up to 4 weeks postnatal. Further research using larger samples to assess possible developmental effects over longer periods of time is required

Withdrawal symptoms in children after long-term administration of sedatives and/or analgesics: A literature review. "Assessment remains troublesome"

Background: Prolonged administration of benzodiazepines and/or opioids to children in a pediatric intensive care unit (PICU) may induce physiological dependence and withdrawal symptoms. Objective: We reviewed the literature for relevant contributions on the nature of these withdrawal symptoms and on availability of valid scoring systems to assess the extent of symptoms. Methods: The databases PubMed, CINAHL, and Psychinfo (1980-June 2006) were searched using relevant key terms. Results: Symptoms of benzodiazepine and opioid withdrawal can be classified in two groups: central nervous system effects and autonomic dysfunction. However, symptoms of the two types show a large overlap for benzodiazepine and opioid withdrawal. Symptoms of gastrointestinal dysfunction in the PICU population have been described for opioid withdrawal only. Six assessment tools for withdrawal symptoms are used in children. Four of these have been validated for neonates only. Two instruments are available to specifically determine withdrawal symptoms in the PICU: the Sedation Withdrawal Score (SWS) and the Opioid Benzodiazepine Withdrawal Scale (OBWS). The OBWS is the only available assessment tool with prospective validation; however, the sensitivity is low. Conclusions: Withdrawal symptoms for benzodiazepines and opioids largely overlap. A sufficiently sensitive instrument for assessing withdrawal symptoms in PICU patients needs to be developed

Inhibition of NF-kB 1 (NF-kBp50) by RNA interference in chicken macrophage HD11 cell line challenged with Salmonellaenteritidis

The NF-kB pathway plays an important role in regulating the immunity response in animals. In this study, small interfering RNAs (siRNA) were used to specifically inhibit NF-kB 1 expression and to elucidate the role of NF-kB in the signal transduction pathway of the Salmonella challenge in the chicken HD11 cell line. The cells were transfected with either NF-kB 1 siRNA, glyceraldehyde 3-phosphate dehydrogenase siRNA (positive control) or the negative control siRNA for 24 h, followed by Salmonella enteritidis (SE) challenge or non-challenge for 1 h and 4 h. Eight candidate genes related to the signal pathway of SE challenge were selected to examine the effect of NF-kB 1 inhibition on their expressions by mRNA quantification. The results showed that, with a 36% inhibition of NF-kB 1 expression, gene expression of both Toll-like receptor (TLR) 4 and interleukin (IL)-6 was consistently and significantly increased at both 1 h and 4 h following SE challenge, whereas the gene expression of MyD88 and IL-1β was increased at 1 h and 4 h, respectively. These findings suggest a likely inhibitory regulation by NF-kB 1, and could lay the foundation for studying the gene network of the innate immune response of SE infection in chickens

Useful pharmacodynamic endpoints in children: selection, measurement, and next steps.

Pharmacodynamic (PD) endpoints are essential for establishing the benefit-to-risk ratio for therapeutic interventions in children and neonates. This article discusses the selection of an appropriate measure of response, the PD endpoint, which is a critical methodological step in designing pediatric efficacy and safety studies. We provide an overview of existing guidance on the choice of PD endpoints in pediatric clinical research. We identified several considerations relevant to the selection and measurement of PD endpoints in pediatric clinical trials, including the use of biomarkers, modeling, compliance, scoring systems, and validated measurement tools. To be useful, PD endpoints in children need to be clinically relevant, responsive to both treatment and/or disease progression, reproducible, and reliable. In most pediatric disease areas, this requires significant validation efforts. We propose a minimal set of criteria for useful PD endpoint selection and measurement. We conclude that, given the current heterogeneity of pediatric PD endpoint definitions and measurements, both across and within defined disease areas, there is an acute need for internationally agreed, validated, and condition-specific pediatric PD endpoints that consider the needs of all stakeholders, including healthcare providers, policy makers, patients, and families.Pediatric Research advance online publication, 11 April 2018; doi:10.1038/pr.2018.38