In a recently released issue of Pediatrics(10.1542/peds.2019-1275), Dr. Neera Goyal and colleagues examine adherence to well-child care among children with intrauterine opioid exposure (IOE). The authors’ retrospective cohort study used data from PEDSnet, which is a comprehensive longitudinal electronic health database that includes all children attending one of 35 primary care sites associated with 8 large pediatric academic centers in 3 states (Florida, Pennsylvania and Delaware). The inclusion and exclusion criteria, and the definitions for the diagnosis of IOE and outcome measures related to well child care adherence through age 2 years are clearly explained. Over the 5-year time period of the study (1/1/2011 – 4/30/2016), a total of 11,334 eligible children completed an initial well care visit, of whom 236 (2.1%) had IOE; those with IOE were more likely to be Medicaid-insured, of white race and lower birthweight, and living in a higher poverty area.
I was surprised to learn that of all children in the study, just 54.1% adhered to AAP recommended well child care (WCC) in the first year of life and 57.1% adhered in the second year of life. If you, however, like me, anticipated that infants with IOE, as compared to those without IOE, would be less likely to adhere to WCC in the first and second years of life, you are correct. The difference between the groups was statistically significant and clinically meaningful: just 25.9% of exposed infants versus 54.7% of non-exposed infants attended expected WCC visits in year one, and 41.5% versus 57.5% attended, respectively, in year two of life. The study examines several relevant secondary outcomes, including up-to-date immunization status, lead screening and the number of sickness visits, all of which are well worth reading about in this study.
The Discussion section of this article is particularly thoughtful and goes well beyond the traditional “more research is needed” usual conclusion often found in a study of this nature. The authors discuss why WCC visits could be particularly meaningful and helpful for mothers with opioid use disorder, and then review the potential applicability and usefulness of alternative models of WCC, including group-based care, mindfulness parenting interventions, clinical outreach from the medical home, and home-visiting. It seems likely to me that partnering with and including affected mothers in this discussion will be critical to future success. While numerous thoughtful professional guidelines exist,1-3 including the voice of mothers who have experienced opioid use disorder may be a key next step to solving the WCC adherence problem for infants with IOE.
References
- Clinical Report: Neonatal Drug Withdrawal. Pediatrics. 2012;129(2):e540-e560. http://pediatrics.aappublications.org/content/129/2/e540. Reaffirmed February 2016.
- Substance Abuse and Mental Health Services Administration. A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorders. HHS Publication No. (SMA) 16-4978. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2016. Available at: http://store.samhsa.gov/
- Opioid use and opioid use disorder in pregnancy. Committee Opinion No. 711. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;130:e81–94.
