County-Level Atrazine Use and Gastroschisis.

Importance: The incidence of gastroschisis, a birth defect involving the herniation of the small bowel through the abdominal wall, has increased in the US since the 1960s. The pesticide atrazine is a hypothesized cause of gastroschisis; however, examination of the association between atrazine and gastroschisis has been limited. Objective: To evaluate national trends in gastroschisis incidence, maternal and infant characteristics associated with gastroschisis, and whether county-level atrazine use is associated with gastroschisis. Design, Setting, and Participants: This retrospective, repeated cross-sectional study examined birth certificate data of all live births in the US and data on atrazine use from the US Geological Survey from January 1, 2009, through December 31, 2019. The data analysis was performed between August 5, 2021, and May 26, 2023. Exposures: County-level atrazine use. Main Outcomes and Measures: The primary outcome was gastroschisis incidence. Covariates included maternal age, race and ethnicity, body mass index (measured by weight in kilograms divided by height in meters squared), parity, insurance type, Chlamydia infection during pregnancy, smoking, and rurality. Mixed-effects logistic regression models (year fixed effects and county random effects) were constructed using different county-level atrazine exposure variables (1-, 5-, and 10-year means). Results: Between 2009 and 2019, 39 282 566 live births were identified, with 10 527 infant diagnoses of gastroschisis. Infants with gastroschisis were more likely to have mothers who identified as non-Hispanic White (61% vs 54%; P < .001), had a lower body mass index (median [IQR], 23.4 [20.8-27.2] vs 25.4 [22.0-30.8]; P < .001), were more likely to be nulliparous (median [IQR], 0 [0-1] vs 1 [0-2]; P < .001), and were more commonly covered by Medicaid (63% vs 43%; P < .001). During the study period, the rate (per 1000 live births) of gastroschisis decreased from 0.31 (95% CI, 0.29-0.33) to 0.22 (95% CI, 0.21-0.24). The median (IQR) county-level atrazine use estimates were higher among infants with gastroschisis (1 year, 1389 [IQR, 198-10 162] vs 1023 [IQR, 167-6960] kg; 5 years, 1425 [IQR, 273-9895] vs 1057 [IQR, 199-6926] kg; 10 years, 1508 [IQR, 286-10 271] vs 1113 [IQR, 200-6650] kg; P < .001). In adjusted models, higher county levels of atrazine (each 100 000-kg increase) were associated with a higher incidence of gastroschisis (1 year: adjusted odds ratio [AOR], 1.12 [95% CI, 1.01-1.24]; 5 years: AOR, 1.15 [95% CI, 1.02-1.30]; 10 years: AOR, 1.21 [95% CI, 1.07-1.38]). Conclusions and Relevance: In this cross-sectional study, higher county levels of atrazine were associated with infant diagnoses of gastroschisis. While atrazine is the second-most used herbicide in the US, numerous countries around the world have banned it out of concern for adverse effects on human health. These findings suggest that exploring alternatives to atrazine in the US may be warranted.

Antipsychotic Medications and Mortality in Children and Young Adults.

Importance: Dose-related effects of antipsychotic medications may increase mortality in children and young adults. Objective: To compare mortality for patients aged 5 to 24 years beginning treatment with antipsychotic vs control psychiatric medications. Design, Setting, and Participants: This was a US national retrospective cohort study of Medicaid patients with no severe somatic illness or schizophrenia or related psychoses who initiated study medication treatment. Study data were analyzed from November 2022 to September 2023. Exposures: Current use of second-generation antipsychotic agents in daily doses of less than or equal to 100-mg chlorpromazine equivalents or greater than 100-mg chlorpromazine equivalents vs that for control medications (α agonists, atomoxetine, antidepressants, and mood stabilizers). Main Outcome and Measures: Total mortality, classified by underlying cause of death. Rate differences (RDs) and hazard ratios (HRs) adjusted for potential confounders with propensity score-based overlap weights. Results: The 2 067 507 patients (mean [SD] age, 13.1 [5.3] years; 1 060 194 male [51.3%]) beginning study medication treatment filled 21 749 825 prescriptions during follow-up with 5 415 054 for antipsychotic doses of 100 mg or less, 2 813 796 for doses greater than 100 mg, and 13 520 975 for control medications. Mortality was not associated with antipsychotic doses of 100 mg or less (RD, 3.3; 95% CI, -5.1 to 11.7 per 100 000 person-years; HR, 1.08; 95% CI, 0.89-1.32) but was associated with doses greater than 100 mg (RD, 22.4; 95% CI, 6.6-38.2; HR, 1.37; 95% CI, 1.11-1.70). For higher doses, antipsychotic treatment was significantly associated with overdose deaths (RD, 8.3; 95% CI, 0-16.6; HR, 1.57; 95% CI, 1.02-2.42) and other unintentional injury deaths (RD, 12.3; 95% CI, 2.4-22.2; HR, 1.57; 95% CI, 1.12-2.22) but was not associated with nonoverdose suicide deaths or cardiovascular/metabolic deaths. Mortality for children aged 5 to 17 years was not significantly associated with either antipsychotic dose, whereas young adults aged 18 to 24 years had increased risk for doses greater than 100 mg (RD, 127.5; 95% CI, 44.8-210.2; HR, 1.68; 95% CI, 1.23-2.29). Conclusions and Relevance: In this cohort study of more than 2 million children and young adults without severe somatic disease or diagnosed psychosis, antipsychotic treatment in doses of 100 mg or less of chlorpromazine equivalents or in children aged 5 to 17 years was not associated with increased risk of death. For doses greater than 100 mg, young adults aged 18 to 24 years had significantly increased risk of death, with 127.5 additional deaths per 100 000 person-years.

Consistency and Adequacy of Public and Commercial Health Insurance for US Children, 2016 to 2021.

Importance: Before and during the COVID-19 public health emergency (PHE), commercially and publicly insured children may have faced different challenges in obtaining consistent and adequate health insurance. Objective: To compare overall rates, COVID-19 PHE-related changes, and child and family characteristics associated with inconsistent and inadequate coverage for publicly and commercially insured children. Design, Settings, and Participants: This was a cross-sectional study using nationally representative data from the 2016 to 2021 National Survey of Children's Health of children from age 0 to 17 years living in noninstitutional settings. Exposure: Parent- or caregiver-reported current child health insurance type defined as public or commercial. Main Outcomes and Measures: Inconsistent insurance, defined as having an insurance gap in the past year; and inadequate insurance, defined by failure to meet 3 criteria: (1) benefits usually/always sufficient to meet child's needs; (2) coverage usually/always allows child to access needed health care practitioners; and (3) no or usually/always reasonable annual out-of-pocket payments for child's health care. Survey-weighted logistic regression was used to compare outcomes by insurance type, by year (2020-2021 vs 2016-2019), and by child characteristics within insurance type. Results: Of this nationally representative sample of 203 691 insured children, 34.5% were publicly insured (mean [SD] age, 8.4 [4.1] years; 47.4% female) and 65.5% were commercially insured (mean [SD] age, 8.7 [5.6]; 49.1% female). Most publicly insured children were either non-Hispanic Black (20.9%) or Hispanic (36.4%); living with 2 married parents (38.4%) or a single parent (33.1%); and had a household income less than 200% of the federal poverty level (79%). Most commercially insured children were non-Hispanic White (62.8%), living with 2 married parents (79.0%); and had a household income of 400% of the federal poverty level or higher (49.1%). Compared with commercially insured children, publicly insured children had higher rates of inconsistent coverage (4.2% vs 1.4%; difference, 2.7 percentage points [pp]; 95% CI, 2.3 to 3.2) and lower rates of inadequate coverage (12.2% vs 33.0%; difference, -20.8 pp; 95% CI, -21.6 to -20.0). Compared with the period from 2016 to 2019, inconsistent insurance decreased by 42% for publicly insured children and inadequate insurance decreased by 6% for commercially insured children during the COVID-19 PHE (2020-2021). The child and family characteristics associated with inadequate and inconsistent insurance varied by insurance type. Conclusions and Relevance: The findings of this cross-sectional study indicate that insurance gaps are a particular problem for publicly insured children, whereas insurance inadequacy and particularly, out-of-pocket costs are a challenge for commercially insured children. Both challenges improved during the COVID-19 PHE. Improving children's health coverage after the PHE will require policy solutions that target the unique needs of commercially and publicly insured children.

Identifying Optimal Methods for Addressing Confounding Bias When Estimating the Effects of State-level Policies.

BACKGROUND: Policy evaluation studies that assess how state-level policies affect health-related outcomes are foundational to health and social policy research. The relative ability of newer analytic methods to address confounding, a key source of bias in observational studies, has not been closely examined. METHODS: We conducted a simulation study to examine how differing magnitudes of confounding affected the performance of 4 methods used for policy evaluations: (1) the two-way fixed effects difference-in-differences model; (2) a 1-period lagged autoregressive model; (3) augmented synthetic control method; and (4) the doubly robust difference-in-differences approach with multiple time periods from Callaway-Sant'Anna. We simulated our data to have staggered policy adoption and multiple confounding scenarios (i.e., varying the magnitude and nature of confounding relationships). RESULTS: Bias increased for each method: (1) as confounding magnitude increases; (2) when confounding is generated with respect to prior outcome trends (rather than levels), and (3) when confounding associations are nonlinear (rather than linear). The autoregressive model and augmented synthetic control method had notably lower root mean squared error than the two-way fixed effects and Callaway-Sant'Anna approaches for all scenarios; the exception is nonlinear confounding by prior trends, where Callaway-Sant'Anna excels. Coverage rates were unreasonably high for the augmented synthetic control method (e.g., 100%), reflecting large model-based standard errors and wide confidence intervals in practice. CONCLUSIONS: In our simulation study, no single method consistently outperformed the others, but a researcher's toolkit should include all methodologic options. Our simulations and associated R package can help researchers choose the most appropriate approach for their data.

Buprenorphine Out-of-Pocket Costs and Discontinuation in Privately Insured Adults With Opioid Use Disorder.

This cohort study examined the association between out-of-pocket costs for an initial buprenorphine prescription and its discontinuation among commercially insured US adults with opioid use disorder.

Medications for Opioid Use Disorder During the Prenatal Period and Infant Outcomes.

This cross-sectional study explores the association between mothers' receipt of opioid use disorder treatment during pregnancy and their infants' health services use in the first year of life.

Patient and Community Factors Affecting Treatment Access for Opioid Use Disorder.

OBJECTIVE: To examine whether access to treatment for women with opioid use disorder (OUD) varied by race and ethnicity, community characteristics, and pregnancy status. METHODS: We conducted a secondary data analysis of a simulated patient caller study of buprenorphine-waivered prescribers and opioid-treatment programs in 10 U.S. states. We conducted multivariable analyses, accounting for potential confounders, to evaluate factors associated with likelihood of successfully securing an appointment. Descriptive statistics and significance testing examined 1) caller characteristics and call outcome by assigned race and ethnicity and clinic type (combined, opioid-treatment programs, and buprenorphine-waivered prescribers) and 2) clinic and community characteristics and call outcome by community race and ethnicity distribution (majority White vs majority Black, Hispanic, Asian, American Indian, Alaska Native, Native Hawaiian, or Pacific Islander) and clinic type. A multiple logistic regression model was fitted to assess the likelihood of obtaining an appointment by callers' race and ethnicity and pregnancy status with the exposure of interest being majority Black, Hispanic, Asian, American Indian, Alaska Native, Native Hawaiian, or Pacific Islander community distribution. RESULTS: In total, 3,547 calls reached clinics to schedule appointments. Buprenorphine-waivered prescribers were more likely to be in communities that were more than 50% White (88.9% vs 77.3%, P<.001), and opioid-treatment programs were more likely to be in communities that were less than 50% White (11.1% vs 22.7%, P<.001). Callers were more likely to be granted appointments in majority Black, Hispanic, Asian, American Indian, Alaska Native, Native Hawaiian, or Pacific Islander communities (adjusted odds ratio [aOR] 1.06, 95% CI 1.02-1.10 per 10% Black, Hispanic, Asian, American Indian, Alaska Native, Native Hawaiian, or Pacific Islander community population) and at opioid-treatment programs (aOR 4.94, 95% CI 3.52-6.92) and if they were not pregnant (aOR 1.79, 95% CI 1.53-2.09). CONCLUSION: Clinic distribution and likelihood of acceptance for treatment varied by community race and ethnicity distribution. Access to treatment for OUD remains challenging for pregnant people and in many historically marginalized U.S. communities.

Maternal Opioid Use Disorder and the Risk of Postneonatal Infant Mortality.

Importance: The risk of serious long-term outcomes for infants born to individuals with opioid use disorder (OUD) is not fully characterized, nor is it well understood whether risks are modified by infant diagnosis of neonatal opioid withdrawal syndrome (NOWS). Objective: To characterize the risk of postneonatal infant mortality among infants with a NOWS diagnosis or born to individuals with OUD. Design, Setting, and Participants: The study team conducted a retrospective cohort study of 390 075 infants born from 2007 through 2018 to mothers who were enrolled in Tennessee Medicaid from 183 days prior to delivery through 28 days post partum (baseline). Maternal and infant baseline characteristics were measured using administrative claims and birth certificates, and infants were followed up from day 29 post partum through day 365 or death. Deaths were identified using linked death certificates through 2019. These data were analyzed from February 10, 2022, through March 3, 2023. Exposure: Infant exposures included birth to an individual with OUD or postnatal diagnosis of NOWS. The study team defined a pregnant individual's OUD status (maternal OUD) as having OUD diagnosis or a maintenance medication prescription fill during baseline; this study defined NOWS as having NOWS diagnosis up to day 28. Groups were categorized by exposures as maternal OUD with NOWS (OUD positive/NOWS positive), maternal OUD without NOWS (OUD positive/NOWS negative), no documented maternal OUD with NOWS (OUD negative/NOWS positive), and no documented maternal OUD or NOWS (OUD negative/NOWS negative, unexposed). Main Outcome and Measures: The outcome was postneonatal infant death, confirmed by death certificates. Cox proportional hazards models were used, adjusting for baseline maternal and infant characteristics, to estimate adjusted hazard ratios (aHRs) and 95% CIs for the association between maternal OUD or NOWS diagnosis with postneonatal death. Results: Pregnant individuals in the cohort had a mean (SD) age of 24.5 (5.2) years; 51% of infants were male. The study team observed 1317 postneonatal infant deaths and incidence rates of 3.47 (OUD negative/NOWS negative, 375 718), 8.41 (OUD positive/NOWS positive, 4922); 8.95 (OUD positive/NOWS negative, 7196), and 9.25 (OUD negative/NOWS positive, 2239) per 1000 person-years. After adjustment, the risk of postneonatal death was elevated for all groups, relative to the unexposed: OUD positive/NOWS positive (aHR, 1.54; 95% CI, 1.07-2.21), OUD positive/NOWS negative (aHR, 1.62; 95% CI, 1.21-2.17), and OUD negative/NOWS positive (aHR, 1.64; 95% CI, 1.02-2.65). Conclusions and Relevance: Infants born to individuals with OUD or with a NOWS diagnosis had an increased risk of postneonatal infant mortality. Future work is necessary to create and evaluate supportive interventions for individuals with OUD during and after pregnancy to reduce adverse outcomes.

County-level Factors and Treatment Access Among Insured Women With Opioid Use Disorder.

BACKGROUND: An over 40% increase in overdose deaths within the past 2 years and low levels of engagement in treatment call for a better understanding of factors that influence access to medication for opioid use disorder (OUD). OBJECTIVE: To examine whether county-level characteristics influence a caller's ability to secure an appointment with an OUD treatment practitioner, either a buprenorphine-waivered prescriber or an opioid treatment program (OTP). RESEARCH DESIGN AND SUBJECTS: We leveraged data from a randomized field experiment comprised of simulated pregnant and nonpregnant women of reproductive age seeking treatment for OUD among 10 states in the US. We employed a mixed-effects logistic regression model with random intercepts for counties to examine the relationship between appointments received and salient county-level factors related to OUD. MEASURES: Our primary outcome was the caller's ability to secure an appointment with an OUD treatment practitioner. County-level predictor variables included socioeconomic disadvantage rankings, rurality, and OUD treatment/practitioner density. RESULTS: Our sample comprised 3956 reproductive-aged callers; 86% reached a buprenorphine-waivered prescriber and 14% an OTP. We found that 1 additional OTP per 100,000 population was associated with an increase (OR=1.36, 95% CI: 1.08 to 1.71) in the likelihood that a nonpregnant caller receives an OUD treatment appointment from any practitioner. CONCLUSIONS: When OTPs are highly concentrated within a county, women of reproductive age with OUD have an easier time securing an appointment with any practitioner. This finding may suggest greater practitioners' comfort in prescribing when there are robust OUD specialty safety nets in the county.

Methodological considerations for estimating policy effects in the context of co-occurring policies.

Understanding how best to estimate state-level policy effects is important, and several unanswered questions remain, particularly about the ability of statistical models to disentangle the effects of concurrently enacted policies. In practice, many policy evaluation studies do not attempt to control for effects of co-occurring policies, and this issue has not received extensive attention in the methodological literature to date. In this study, we utilized Monte Carlo simulations to assess the impact of co-occurring policies on the performance of commonly-used statistical models in state policy evaluations. Simulation conditions varied effect sizes of the co-occurring policies and length of time between policy enactment dates, among other factors. Outcome data (annual state-specific opioid mortality rate per 100,000) were obtained from 1999 to 2016 National Vital Statistics System (NVSS) Multiple Cause of Death mortality files, thus yielding longitudinal annual state-level data over 18 years from 50 states. When co-occurring policies are ignored (i.e., omitted from the analytic model), our results demonstrated that high relative bias (> 82%) arises, particularly when policies are enacted in rapid succession. Moreover, as expected, controlling for all co-occurring policies will effectively mitigate the threat of confounding bias; however, effect estimates may be relatively imprecise (i.e., larger variance) when policies are enacted in near succession. Our findings highlight several key methodological issues regarding co-occurring policies in the context of opioid-policy research yet also generalize more broadly to evaluation of other state-level policies, such as policies related to firearms or COVID-19, showcasing the need to think critically about co-occurring policies that are likely to influence the outcome when specifying analytic models.

Prevalence of Buprenorphine Providers Requiring Cash Payment From Insured Women Seeking Opioid Use Disorder Treatment.

CONTEXT: Medications for opioid use disorder (OUD) are known to be effective, especially in reducing the risk of overdose death. Yet, many individuals suffering from OUD are not receiving treatment. One potential barrier can be the patient's ability to access providers through their insurance plans. DATA AND METHODS: We used an audit (simulated patient) study methodology to examine appointment-granting behavior by buprenorphine prescribers in 10 different US states. Trained callers posed as women with OUD and were randomly assigned Medicaid or private insurance status. Callers request an OUD treatment appointment and then asked whether they would be able to use their insurance to cover the cost of care, or alternatively, whether they would be required to pay fully out-of-pocket. FINDINGS: We found that Medicaid and privately insured women were often asked to pay cash for OUD treatment--40% of the time over the full study sample. Such buprenorphine provider requests happened more than 60% of the time in some states. Areas with more providers or with more generous provider payments were not obviously more willing to accept the patient's insurance benefits for OUD treatment. Rural providers were less likely to require payment in cash in order for the woman to receive care. CONCLUSIONS: State-to-state variation was the most striking pattern in our field experiment data. The wide variation suggests that women of reproductive age with OUD in certain states face even greater challenges to treatment access than perhaps previously thought; however, it also reveals that some states have found ways to curtail this problem. Our findings encourage greater attention to this public health challenge and possibly opportunities for shared learning across states.

Treatment access for opioid use disorder among women with medicaid in Florida.

INTRODUCTION: Opioid use disorder (OUD) remains prevalent. Medications for OUD (MOUD) are standard care for pregnant and non-pregnant women. Previous research has identified barriers to MOUD for women with Medicaid but did not account for the type of MOUD (methadone vs. buprenorphine) or pregnancy status. We examined access to MOUD by treatment type for pregnant and non-pregnant women with Medicaid in Florida. METHODS: A secondary analysis of Florida "secret-shopper" data was conducted. Calls were made to clinicians from the 2018 Substance Abuse and Mental Health Services Administration provider list by women posing as either a pregnant or non-pregnant woman with OUD and Medicaid. We examined 546 calls to buprenorphine-waivered providers (BWP) and 139 to opioid treatment programs (OTP). Counts and percentages were used to describe caller success by type of treatment and pregnancy status. Chi-square tests were used to identify statistical differences. RESULTS: Only 42 % of calls reached a treatment provider in Florida. Pregnant and non-pregnant women were less likely to obtain an appointment with Medicaid coverage by a BWP than an OTP (p < 0.01). Nearly 40 % of OTPs offered appointments to callers with Medicaid compared to only 17 % of BWPs. Both types of providers denied appointments more often for pregnant women. Thirty-eight percent of BWP's and 12 % of OTP's denied appointments to pregnant women using cash or Medicaid payment. CONCLUSIONS: Our study demonstrates logistical and financial barriers to treatment for OUD among pregnant and non-pregnant women with Medicaid in Florida and highlights the need for improved systems of care.

Trends in Neonatal Extracorporeal Membrane Oxygenation During a Venovenous Cannula Shortage.

OBJECTIVES: To report temporal trends in venovenous extracorporeal membrane oxygenation (ECMO) use for neonatal respiratory failure in U.S. centers before and after functional venovenous cannula shortage due to withdrawal of one dual lumen venovenous cannula from the market in 2018. DESIGN: Retrospective cohort study. SETTING: ECMO registry of the Extracorporeal Life Support Organization. PATIENTS: Infants who received neonatal (cannulated prior to 29 d of age) respiratory ECMO at a U.S. center and had a record available in the ECMO registry from January 1, 2010 to July 20, 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Primary outcome was receipt of venovenous ECMO (vs venoarterial or other), and secondary outcomes were survival to hospital discharge and adverse neurologic outcomes. Using an interrupted time series design, we fit multivariable mixed effects logistic regression models with receipt of venovenous ECMO as the dependent variable, treatment year modeled as a piecewise linear variable using three linear splines (pre shortage: 2010-2014, 2014-2018; shortage: 2018-2021), and adjusted for center clustering and multiple covariates. We evaluated trends in venovenous ECMO use by primary diagnosis including congenital diaphragmatic hernia, meconium aspiration, pulmonary hypertension, and other. Annual neonatal venovenous ECMO rates decreased after 2018: from 2010 to 2014, adjusted odds ratio (aOR) for yearly trend 0.98 (95% CI 0.92-1.04), from 2014 to 2018, aOR for yearly trend 0.90 (95% CI 0.80-1.01), and after 2018, aOR for yearly trend 0.46 (95% CI 0.37-0.57). We identified decreased venovenous ECMO use after 2018 in all diagnoses evaluated, and we failed to identify differences in temporal trends between diagnoses. Survival and adverse neurologic outcomes were unchanged across the study periods. CONCLUSIONS: Venovenous ECMO for neonatal respiratory failure in U.S. centers decreased after 2018 even after accounting for temporal trends, coincident with withdrawal of one of two venovenous cannulas from the market.

The Association between NICU Admission and Mental Health Diagnoses among Commercially Insured Postpartum Women in the US, 2010-2018.

Maternal mental health (MH) conditions represent a leading cause of preventable maternal death in the US. Neonatal Intensive Care Unit (NICU) hospitalization influences MH symptoms among postpartum women, but a paucity of research uses national samples to explore this relationship. Using national administrative data, we examined the rates of MH diagnoses of anxiety and/or depression among those with and without an infant admitted to a NICU between 2010 and 2018. Using generalized estimating equation models, we explored the relationship between NICU admission and MH diagnoses of anxiety and/or depression, secondarily examining the association of NICU length of stay and race/ethnicity with MH diagnoses of anxiety and/or depression post NICU admission. Women whose infants became hospitalized in the NICU for <2 weeks had 19% higher odds of maternal MH diagnoses (aOR: 1.19, 95% CI: 1.14%−1.24%) and those whose infants became hospitalized for >2 weeks had 37% higher odds of maternal MH diagnoses (aOR: 1.37 95% CI: 1.128%−1.47%) compared to those whose infants did not have a NICU hospitalization. In adjusted analyses, compared to white women, all other race/ethnicities had significantly lower odds of receiving a maternal MH condition diagnosis [Black (aOR = 0.76, 0.73−0.08), Hispanic (aOR = 0.69, 0.67−0.72), and Asian (aOR: 0.32, 0.30−0.34)], despite higher rates of NICU hospitalization. These findings suggest a need to target the NICU to improve maternal MH screening, services, and support while acknowledging the influence of social determinants, including race and ethnicity, on health outcomes.

Recommended Terminology for Substance Use Disorders in the Care of Children, Adolescents, Young Adults, and Families.

Pediatricians across the United States encounter infants, children, adolescents, young adults, and families affected by substance use disorders in their daily practice. For much of history, substance use has been viewed as a moral failing for which individuals themselves are to blame; however, as addiction became understood as a medical disorder, clinical terminology has shifted along with a growing awareness of harm of stigmatizing language in medicine. In issuing this policy statement, the American Academy of Pediatrics (AAP) joins other large organizations in providing recommendations regarding medically accurate, person-first, and nonstigmatizing terminology. As the first pediatric society to offer guidance on preferred language regarding substance use to be used among pediatricians, media, policymakers, and government agencies and in its own peer-reviewed publications, the AAP aims to promote child health by highlighting the specific context of infants, children, adolescents, young adults, and families. In this policy statement, the AAP provides 3 specific recommendations, accompanied by a table that presents a summary of problematic language to be avoided, paired with the recommended more appropriate language and explanations for each. Pediatricians have an important role in advocating for the health of children and adolescents in the context of families affected by substance use and are optimally empowered to do so by avoiding the use of stigmatizing language in favor of medically accurate terminology that respects the dignity and personhood of individuals with substance use disorders and the children and adolescents raised in families affected by substance use.

Risk of Death at 1 Year Following Postpartum Opioid Exposure.

OBJECTIVE: Opioids are commonly prescribed to women for acute pain following childbirth. Postpartum prescription opioid exposure is associated with adverse opioid-related morbidities but the association with all-cause mortality is not well studied. This study aimed to examine the association between postpartum opioid prescription fills and the 1-year risk of all-cause mortality among women with live births. METHODS: In a retrospective cohort study of live births among women enrolled in Tennessee Medicaid (TennCare) between 2007 and 2015, we compared women who filled two or more postpartum outpatient opioid prescriptions (up to 41 days of postdelivery discharge) to women who filled one or fewer opioid prescription. Women were followed from day 42 postdelivery discharge through 365 days of follow-up or date of death. Deaths were identified using linked death certificates (2007-2016). We used Cox's proportional hazard regression and inverse probability of treatment weights to compare time to death between exposure groups while adjusting for relevant confounders. We also examined effect modification by delivery route, race, opioid use disorder, use of benzodiazepines, and mental health condition diagnosis. RESULTS: Among 264,135 eligible births, 216,762 (82.1%) had one or fewer maternal postpartum opioid fills and 47,373 (17.9%) had two or more fills. There were 182 deaths during follow-up. The mortality rate was higher in women with two or more fills (120.5 per 100,000 person-years) than in those with one or fewer (57.7 per 100,000 person-years). The risk of maternal death remained higher in participants exposed to two or more opioid fills after accounting for relevant covariates using inverse probability of treatment weighting (adjusted hazard ratio: 1.46 [95% confidence interval: 1.01, 2.09]). Findings from stratified analyses were consistent with main findings. CONCLUSION: Filling two or more opioid prescriptions during the postpartum period was associated with a significant increase in 1-year risk of death among new mothers. KEY POINTS: · Opioid prescribing in the postpartum period is common.. · Prior studies show that >1 postnatal opioid fill is associated with adverse opioid-related events.. · > 1 opioid fill within 42 days of delivery was associated with an increase in 1-year risk of death..

Factors Associated With Parental COVID-19 Vaccination Acceptance.

As the coronavirus pandemic continues to impact families and children, understanding parental attitudes and likely acceptance of the COVID-19 vaccine is essential. We conducted a statewide survey with a representative sample of parents in Tennessee focused on COVID-19 and influenza vaccine acceptance and perspectives. Data from 1066 parents were analyzed using weighted survey methods to generalize results to the state of Tennessee. About 53% of parents reported a likelihood to vaccinate their children against COVID-19, and 45% were likely to vaccinate their child against COVID-19 and influenza. Female parents were less likely to vaccinate their children against COVID-19, but the strongest predictor of likely COVID-19 vaccine acceptance was influenza vaccine acceptance (adjusted odds ratio = 5.46; 95% confidence interval: 3.20-9.30). Parental acceptance of COVID-19 vaccines for children is closely tied to influenza vaccine acceptance. Public health approaches to maximize vaccine uptake could focus on children who have not been receiving influenza vaccines.

Impact of stigmatizing language describing opioid-exposed mother infant dyads: A randomized case vignette study.

Background: Existing literature suggests that using stigmatizing language may promote negative attitudes and result in more punitive views toward individuals with addiction. It is unclear how the commonly used colloquial terms to describe opioid-exposed mother infant dyads impacts public opinion of pregnant women with opioid use disorder (OUD). We sought to examine the extent to which language such as "opioid addict" and "born addicted" influences the perception of pregnant women with OUD. Methods: We conducted a randomized case-based vignette study using a population-weighted sample of parents living in Tennessee, varying in the language used to describe an opioid-exposed mother infant dyad. Participant demographics, views on opioid prescribing, and opinions on criminal justice and child welfare responses following delivery were obtained. Ordinal logistic regression was used to examine the association between vignette type and punitive responses. Results: Eleven hundred participants completed the survey. Overall, 30.6% felt the mother should be arrested and 68.6% felt the mother should lose custody of her infant. There was insufficient evidence to suggest a difference in punitive response selection based on the vignette language (p = 0.27). In the adjusted model, the odds of answering a more punitive response among parents who received non-stigmatizing language was 0.8 (95% CI 0.59-1.08) compared to parents who received stigmatizing language in the vignette. Conclusions: Many parents hold punitive views toward mothers receiving OUD treatment that was not altered by using less value-laden language. Broader stigma-reduction interventions may be more effective.

Using Public Health Surveillance Data to Determine Hepatitis C Virus Exposure Among Live-Born Infants in Tennessee, 2013-2017.

OBJECTIVE: Maternal hepatitis C virus (HCV) infection reported on birth certificates has been shown to underestimate HCV infection. We sought to determine the usefulness of HCV surveillance data for (1) quantifying the number of HCV-positive reproductive-aged women with a live birth, (2) comparing maternal HCV surveillance data with reported HCV infection status on birth certificates, and (3) delineating past versus current maternal infection to identify true perinatal exposures. METHODS: We extracted data from January 1, 2013, through December 31, 2017, on birth certificate indication of HCV exposure from the Tennessee Birth Statistical File, and we ascertained indication of HCV exposure by using laboratory data from the Tennessee National Electronic Disease Surveillance System (NEDSS) Base System (NBS). We conducted a sensitivity analysis comparing birth certificate indication of HCV exposure with HCV laboratory data to determine whether true perinatal exposure had occurred. RESULTS: During the study period, 6731 mothers with live births in Tennessee reported having HCV infection during pregnancy: 3295 (49.0%) had both laboratory and birth certificate indication of HCV infection, 2130 (31.6%) had indication of HCV infection on the laboratory report only, and 1306 (19.4%) had indication of HCV infection on the birth certificate only. CONCLUSIONS: Using data from a public health HCV surveillance system with birth certificate data may improve the identification of HCV-infected pregnant women and perinatally exposed infants. Surveillance systems that include complete reporting of all HCV RNA results can be used to distinguish past from present maternal HCV infection to focus limited public health resources on currently infected mothers and their exposed infants.