Increased incidence of Neonatal Opioid Withdrawal Syndrome has prompted innovation in assessment and management approaches. The Finnegan Approach and the Eat, Sleep, Console are the two most commonly described approaches...Increased incidence of Neonatal Opioid Withdrawal Syndrome has prompted innovation in assessment and management approaches. The Finnegan Approach and the Eat, Sleep, Console are the two most commonly described approaches, though they differ substantially. The goals of this review article are to describe and compare these approaches and published outcomes, including areas of uncertainty that may inform future directions.
There has been a significant paradigm shift in the management of infants with NOWS to emphasizing the role of non-pharmacologic care centered on the mother-infant dyad. By promoting bonding through rooming-in, breast-fee...There has been a significant paradigm shift in the management of infants with NOWS to emphasizing the role of non-pharmacologic care centered on the mother-infant dyad. By promoting bonding through rooming-in, breast-feeding and skin-to skin contact in a low stimulation environment, short and long-term outcomes have dramatically improved, resulting in reduced length of stay and need for pharmacologic treatment of the newborn. This shift in care also empowers the mother and promotes bonding and attachment, providing a solid foundation for a safe discharge. When non-pharmacological treatments are not sufficient to control the infant's withdrawal symptoms then medications can be used as an adjunct, to the minimum extent necessary and should never be used in isolation of non-pharmacological interventions. Quality improvement efforts should focus on optimizing and standardizing both non-pharmacologic and pharmacologic care to best serve this population.
Nidey N, Gerdts G, Kavouras M
… +1 more, Schiff DM
Semin Perinatol
· 2025 Feb · PMID 39667978
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Pregnant and parenting people with opioid use disorder commonly experience stigma, or the enactment of negative attitudes, beliefs, and stereotypes, during their pregnancy and at delivery. We will describe four different...Pregnant and parenting people with opioid use disorder commonly experience stigma, or the enactment of negative attitudes, beliefs, and stereotypes, during their pregnancy and at delivery. We will describe four different domains of stigma: self, interpersonal, structural, and policy, and discuss how they intersect to amplify the experiences of shame, anxiety, isolation, lack of trust for birthing people and parents that can contribute to the avoidance of prenatal care and substance use treatment which can impact pregnancy and infant health outcomes. We will review a case example where stigma contributed to poor care, review preferred person-first language to use when talking to and about families impacted by opioid use disorder, and describe emerging interventions to address and mitigate the effects of stigma in the perinatal setting.
Semin Perinatol
· 2025 Feb · PMID 39648070
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The long-term outcomes of children exposed to opioids and other substances in utero, specifically those diagnosed with Neonatal Abstinence Syndrome (NAS), present a complex interaction of different factors. First, NAS an...The long-term outcomes of children exposed to opioids and other substances in utero, specifically those diagnosed with Neonatal Abstinence Syndrome (NAS), present a complex interaction of different factors. First, NAS and its clinical presentation will be defined, then summarized will be an overview of NAS prevalence, recent trends, and significance of NAS in the context of the rising synthetic opioid and polysubstance use. Highlighted will also be the identified risk factors for NAS, especially regarding the role of environmental and psychosocial stressors during pregnancy. Finally, reviewed will be the existing NAS literature, including its gaps and limitations, and suggested recommendations for future research and policy considerations for improving care for children and families impacted by NAS.
Neonatal Abstinence Syndrome (NAS) after in-utero exposure to opioids remains a significant public health concern. NAS is a highly variable condition in which presentation and severity cannot be explained by clinical fac...Neonatal Abstinence Syndrome (NAS) after in-utero exposure to opioids remains a significant public health concern. NAS is a highly variable condition in which presentation and severity cannot be explained by clinical factors alone. Research in human subjects has identified both genetic and epigenetic associations with prenatal opioid exposure and NAS severity, including single nucleotide polymorphisms, DNA methylation differences, and gene expression modifications. Animal studies have also identified key gene pathways that are likely important contributors to NAS phenotype. The clinical significance of identified genetic associations with NAS are unclear and warrant further study to see how they could impact NAS management.
The way we enact screening for substance use during pregnancy within our healthcare systems can work by decreasing stigma, promoting engagement, and supporting people with reaching the end of their pregnancy in a manner...The way we enact screening for substance use during pregnancy within our healthcare systems can work by decreasing stigma, promoting engagement, and supporting people with reaching the end of their pregnancy in a manner where the newborn can be well supported. The way we enact biochemical specimen toxicology testing for substance use during pregnancy and in newborns contributes to increased stigma, disengagement from care, and potential continuation of uncontrolled substance use up until delivery such that the newborn may not be able to be well supported in the family environment. These effects are inequitably distributed, leading to worse outcomes for families of color and families living in poverty. Serial screening with a validated questionnaire starting at the first prenatal visit and continuing through the delivery hospitalization should occur and be followed up with service connections and substance use disorder diagnosis and treatment. Newborn toxicology testing as a diagnostic tool for risk of withdrawal or the etiology of potential withdrawal symptoms represents a failure in the effectiveness of compassionate communication by healthcare providers with the birthing person. Given the current level of evidence of clinical utility and the inequitable consequences specific to these tests, they are rarely needed.
Treatment of perinatal opioid use disorder should center the mother-infant dyad, the needs of both entities, and preservation of the relationship. The criminalization of pregnancy and substance use in pregnancy through p...Treatment of perinatal opioid use disorder should center the mother-infant dyad, the needs of both entities, and preservation of the relationship. The criminalization of pregnancy and substance use in pregnancy through punitive policies and legislation and the involvement of the family policing system are in direct opposition to compassionate, person-centered care and lead to worse maternal and neonatal outcomes. In this chapter, we review the history and ongoing criminalization of pregnancy and perinatal substance use disorder, explore carcerality as a barrier to dyadic care that disproportionately targets Black, Brown, and Indigenous birthing individuals, and propose solutions to decriminalize care based in abolition medicine and reproductive justice frameworks.
Neonatal Opioid Withdrawal Syndrome (NOWS) is a group of clinical withdrawal signs occurring in prenatally opioid-exposed newborns and manifesting as neurobehavioral dysregulation, including extreme irritability such as...Neonatal Opioid Withdrawal Syndrome (NOWS) is a group of clinical withdrawal signs occurring in prenatally opioid-exposed newborns and manifesting as neurobehavioral dysregulation, including extreme irritability such as excessive crying, rigid muscle tone, and difficulty feeding and sleeping. One U.S. infant experiencing NOWS is born every 25 min. Clinical management of these infants has traditionally occurred in the high-acuity environment of a neonatal intensive care unit (NICU), which contributes to separation of infants from their parents and increases the likelihood of pharmacological intervention to manage withdrawal. Over the past decade, more holistic approaches, such as the Eat, Sleep, and Console method, have focused on parents' active participation in care, rooming-in, and implementation of non-pharmacologic soothing techniques to reduce medication use, hospital length of stay, and healthcare expenditures. These distinctly different management approaches have contributed to unique experiences for parents and healthcare providers involved in infants' care; therefore, the purpose of this paper is to review the experiences of parents and healthcare providers as they relate to management approaches for infants with NOWS.
Climate change's impact on global food security is a pressing concern with profound consequences. Climate change disrupts the global food system through a number of mechanisms including extreme weather events, rising foo...Climate change's impact on global food security is a pressing concern with profound consequences. Climate change disrupts the global food system through a number of mechanisms including extreme weather events, rising food prices, and compromised food quality. In this article, we explore the effect of climate change on food security and the resulting health impacts of poor nutrition on pregnant women and infants in the perinatal period. Inadequate nutrition during pregnancy raises the risk of vitamin deficiencies, obstetric complications, maternal mortality, and infant malnutrition. Climate change exacerbates these challenges and perpetuates intergenerational cycles of poor nutrition. Addressing these issues requires traditional approaches to combating the climate impacts on general food security as well as specific approaches to bridge the food security gender gap. Empowering women as key stakeholders is crucial for overcoming the complex barriers to food insecurity caused by climate change, as well as protecting the well-being of vulnerable populations during the perinatal period.
Severe bronchopulmonary dysplasia (sBPD) requiring invasive mechanical ventilation is a heterogeneous disease process that contributes to morbidity and mortality in infants. As the most common lung disease of prematurity...Severe bronchopulmonary dysplasia (sBPD) requiring invasive mechanical ventilation is a heterogeneous disease process that contributes to morbidity and mortality in infants. As the most common lung disease of prematurity, sBPD has a multitude of overlapping cardiac, airway, pulmonary vascular, and infectious phenotypic presentations that progress through four different phases of care. Premature infants with sBPD are at a high risk of acute decompensation and subsequent cardiopulmonary arrest. A comprehensive determination of the complex phenotypes that contribute to the clinical presentation will help clinicians decipher the phase of care, identify cardiopulmonary compromise earlier and guide targeted therapeutic intervention during acute episodes of deterioration. The approach to resuscitation of premature infants with sBPD undergoing an acute decompensation differs from general neonatal and pediatric resuscitation practices. This review summarizes the phenotypes of sBPD, the phases of care, the common triggers of acute exacerbations, and the principles of resuscitation of a deteriorating infant with sBPD. We offer a framework for sBPD resuscitation with a focus on prevention, assessment, and post-resuscitative care.
Neonatal intensive care unit resuscitative care continually evolves and increasingly relies on data. Data driven precision resuscitation care can be enabled by leveraging informatics tools and artificial intelligence. De...Neonatal intensive care unit resuscitative care continually evolves and increasingly relies on data. Data driven precision resuscitation care can be enabled by leveraging informatics tools and artificial intelligence. Despite technological advancements, these data are often underutilized due to suboptimal data capture, aggregation, and low adoption of artificial intelligence and analytic tools. This review describes the fundamentals and explores the evidence behind informatics and artificial intelligence tools supporting neonatal intensive care unit resuscitative care, training and education. Key findings include the need for effective interface design for accurate data capture followed by storage and translation to wisdom using analytics and artificial intelligence tools. This review addresses the issues of data privacy, bias, liability and ethical frameworks when adopting these tools. While these emerging technologies hold great promise to improve resuscitation, further study of these applications in neonatal population and awareness of informatics and artificial intelligence principles among clinicians is imperative.
Effective resuscitation of neonates with congenital heart disease (CHD) depends on comprehensive planning, thorough understanding of physiology, vigilant monitoring, and interdisciplinary collaboration to achieve the bes...Effective resuscitation of neonates with congenital heart disease (CHD) depends on comprehensive planning, thorough understanding of physiology, vigilant monitoring, and interdisciplinary collaboration to achieve the best outcomes. Neonatal heart disease can affect cardiac structure, rhythm, or ventricular function, and may be either congenital or acquired. Critical congenital heart disease (CCHD) can result in inadequate pulmonary blood flow, impaired intracardiac mixing, airway obstruction, or insufficient cardiac output. Tailored resuscitation strategies are important as early as the delivery room, where some CHD lesions may cause immediate cardiovascular instability during the transition from fetal to postnatal circulation. Premature infants with CHD are at higher risk due to their small size and the complications associated with prematurity, affecting both CHD management and overall clinical stability. Addressing both cardiac and non-cardiac causes of decompensation requires a precise understanding of each patient's unique physiology and trajectory from delivery through postintervention intensive care.
Resuscitation of an infant with surgical complications includes both perioperative and post-operative management. In most cases this requires a multidisciplinary approach to achieve the best outcomes. Challenges include...Resuscitation of an infant with surgical complications includes both perioperative and post-operative management. In most cases this requires a multidisciplinary approach to achieve the best outcomes. Challenges include immediate expert management at infant delivery with the use of protocolized care, available anesthesia expertise, close monitoring of electrolytes with prompt attention to fluid status, and meticulous pain management. In this review, we will address contemporary research and ongoing challenges associated with resuscitation. We will make recommendations for effective resuscitation of this vulnerable and unique population from premature infant to term infant with complex surgical needs.
Stanaj L, Goffman D, Genow B
… +3 more, Meccariello L, Ewing J, Michaels I
Semin Perinatol
· 2024 Nov · PMID 39448281
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For the purposes of this review, obstetric sepsis refers to sepsis (from all causes, including non-obstetric such as pneumonia) in pregnant or postpartum patients, which was previously described as maternal sepsis. Obste...For the purposes of this review, obstetric sepsis refers to sepsis (from all causes, including non-obstetric such as pneumonia) in pregnant or postpartum patients, which was previously described as maternal sepsis. Obstetric sepsis poses a significant threat to pregnant, birthing, and postpartum individuals, contributing prominently to maternal mortality and morbidity despite being largely preventable. In response to identified gaps in sepsis management, particularly the lack of specific protocols tailored to obstetric populations, New York-Presbyterian undertook a system-wide initiative to implement a comprehensive sepsis bundle. This initiative included the development of new criteria for identifying sepsis in obstetric patients, the creation of electronic medical record (EMR) alerts aligned with obstetric-specific indicators, and the establishment of a structured sepsis management algorithm. The project involved collaboration across eight hospital campuses within the New York-Presbyterian system, aiming to standardize and improve the early recognition and treatment of sepsis in maternal care. Key components included rigorous data analysis to select appropriate sepsis criteria, simulation-based training to familiarize clinical teams with the new algorithm, and continuous refinement of alert systems to mitigate alarm fatigue and enhance responsiveness. Post-implementation evaluation revealed a significant reduction in preventable morbidity related to sepsis, accompanied by the identification of additional gaps in fever and chorioamnionitis management. These findings prompted the development of new clinical guidelines to further enhance patient safety. Challenges encountered included adapting sepsis criteria to balance sensitivity and specificity, as well as integrating trauma-informed care principles into clinical practice. This project underscores the effectiveness of tailored quality improvement efforts in maternal health, emphasizing the critical role of proactive interventions in enhancing patient outcomes and safety within obstetric settings. Ongoing efforts focus on monitoring process metrics through a dedicated sepsis dashboard and advancing education on trauma-informed care principles, highlighting the continued commitment to sustained improvement in maternal health outcomes.
It is not uncommon for a patient to experience hemodynamic instability following birth. This is due to the fact that the transitional period requires dramatic cardiorespiratory changes. When it goes well, improved lung c...It is not uncommon for a patient to experience hemodynamic instability following birth. This is due to the fact that the transitional period requires dramatic cardiorespiratory changes. When it goes well, improved lung compliance and successful transition to the postnatal circulation is seen. However, it is highly beneficial that clinicians have a solid understanding of all of the required changes, the unique aspects of the neonatal myocardium, and the influence of cardiovascular disease on normal adaptive mechanisms. In this manuscript, we will review the physiology of the normal postnatal circulatory adaptation, the unique characteristics of the neonatal myocardium and how it behaves in states of altered loading conditions, and the impact of hemodynamic disease states on health and wellbeing during the immediate postnatal time-period.
Cardiopulmonary resuscitation is a critical component of neonatal care. While the basic principles of resuscitation are consistent across different settings, the specific challenges and resources available in the deliver...Cardiopulmonary resuscitation is a critical component of neonatal care. While the basic principles of resuscitation are consistent across different settings, the specific challenges and resources available in the delivery room and the Neonatal Intensive Care Unit (NICU) vary significantly. Understanding the differences between these settings is essential for optimizing resuscitation outcomes. This article explores four key areas of difference-environment and equipment, team composition and roles, care protocols and practices, and patient population and condition-and how they impact neonatal resuscitation efforts. By examining these differences, healthcare neonatal care teams can better prepare for the specific resuscitation needs in each setting, ultimately improving neonatal survival and long-term health outcomes.