Prenatal opioid exposure by likelihood of exposure and risk to prenatal development: Medicaid-covered births in Wisconsin, 2010-2019.

Prenatal opioid exposure is an established public health problem, in particular among Medicaid-covered births. Yet, existing prevalence rates are plausibly underestimated. We leverage extensive linked longitudinal administrative data for all Medicaid-covered live births in Wisconsin from 2010 to 2019 to estimate a range of prevalence rates using an innovative strategy that jointly accounts for both likelihood of exposure and potential risk to prenatal development. We find that 20.8% of infants may have been prenatally exposed to opioids, with 1.7% diagnosed with neonatal abstinence syndrome and an additional 1.2% having a high combined likelihood of exposure and potential risk to prenatal development, 2.6% a moderate combined likelihood and risk, and 15.3% a low or uncertain combined likelihood and risk. We assess improvements in prevalence estimates based on our nuanced classification relative to those of prior studies. Our strategy could be broadly used to quantify the scope of the opioid crisis for pregnant populations, target interventions, and promote child health and development.

Trends in prenatal prescription opioid use among Medicaid beneficiaries in Wisconsin, 2010-2019.

OBJECTIVE: To examine changes in prenatal opioid prescription exposure following new guidelines and policies. STUDY DESIGN: Cohort study of all (262,284) Wisconsin Medicaid-insured live births 2010-2019. Prenatal exposures were classified as analgesic, short term, and chronic (90+ days), and medications used to treat opioid use disorder (MOUD). We describe overall and stratified temporal trends and used linear probability models with interaction terms to test their significance. RESULT: We found 42,437 (16.2%) infants with prenatal exposure; most (90.5%) reflected analgesic opioids. From 2010 to 2019, overall exposure declined 12.8 percentage points (95% CI = 12.1-13.1). Reductions were observed across maternal demographic groups and in both rural and urban settings, though the extent varied. There was a small reduction in chronic analgesic exposure and a concurrent increase in MOUD. CONCLUSION: Broad and sustained declines in prenatal prescription opioid exposure occurred over the decade, with little change in the percentage of infants chronically exposed.

Paid family leave and parental investments in infant health: Evidence from California.

This paper evaluates the effect of Paid Family Leave (PFL) on breastfeeding and immunizations- two critical parental investments in infant health - which we identify using California's 2004 PFL policy that ensured mothers up to six weeks of leave at a 55% wage replacement rate. We employ difference-in-difference and difference-in-difference-in-differences models for a large, representative sample of children (N = 314,532) born between 2000 and 2013 drawn from the restricted-use versions of the 2003-2014 National Immunization Surveys. Our most conservative estimates indicate that access to PFL is associated with at least a 15% increase in breastfeeding exclusively for at least six months. We find substantially large effects for disadvantaged mothers, adding to the existing evidence that access to state-sanctioned paid family leave might benefit children overall and disadvantaged children in particular.

Duration and Timing of In Utero Opioid Exposure and Incidence of Neonatal Withdrawal Syndrome.

OBJECTIVE: To evaluate the association between prenatal prescription opioid analgesic exposure (duration, timing) and neonatal opioid withdrawal syndrome (NOWS). METHODS: We conducted a retrospective cohort study of Wisconsin Medicaid-covered singleton live births from 2011 to 2019. The primary outcome was a NOWS diagnosis in the first 30 days of life. Opioid exposure was identified with any claim for prescription opioid analgesic fills during pregnancy. We measured exposure duration cumulatively in days (1-6, 7-29, 30-89, and 90 or more) and identified timing as early (first two trimesters only) or late (third trimester, regardless of earlier pregnancy use). We used logistic regression modeling to assess NOWS incidence by exposure duration and timing, with and without propensity score matching. RESULTS: Overall, 31,456 (14.3%) of 220,570 neonates were exposed to prescription opioid analgesics prenatally. Among exposed neonates, 19,880 (63.2%) had 1-6 days of exposure, 7,694 (24.5%) had 7-29 days, 2,188 (7.0%) had 30-89 days, and 1,694 (5.4%) had 90 or more days of exposure; 15,032 (47.8%) had late exposure. Absolute NOWS incidence among neonates with 1-6 days of exposure was 7.29 per 1,000 neonates (95% CI 6.11-8.48), and incidence increased with longer exposure: 7-29 days (19.63, 95% CI 16.53-22.73); 30-89 days (58.96, 95% CI 49.08-68.84); and 90 or more days (177.10, 95% CI 158.90-195.29). Absolute NOWS incidence for early and late exposures were 11.26 per 1,000 neonates (95% CI 9.65-12.88) and 35.92 per 1,000 neonates (95% CI 32.95-38.90), respectively. When adjusting for confounders including timing of exposure, neonates exposed for 1-6 days had no increased odds of NOWS compared with unexposed neonates, whereas those exposed for 30 or more days had increased odds of NOWS (30-89 days: adjusted odds ratio [aOR] 2.15, 95% CI 1.22-3.79; 90 or more days: 2.80, 95% CI 1.36-5.76). Late exposure was associated with elevated odds of NOWS (aOR 1.57, 95% CI 1.25-1.96) when compared with unexposed after adjustment for exposure duration. CONCLUSION: More than 30 days of prenatal prescription opioid exposure was associated with NOWS regardless of exposure timing. Third-trimester opioid exposure, irrespective of exposure duration, was associated with NOWS.

Child Maltreatment: A Comparison of Wisconsin Children Identified in Health Care and Child Protective Services (CPS) Records, 2018-2019.

CONTEXT: Child Protective Services (CPS) reports and health records (hospital inpatient and emergency department visits) are the primary data sources to measure child maltreatment; yet, they are not linked at the state or national level. Linking provides novel insight into the demographic characteristics of the populations served by one or both agencies, thus informing opportunities for prevention and intervention. OBJECTIVE: This study compares children identified as maltreated in health records (based on International Classification of Diseases, Tenth Revision, Clinical Modification [ ICD-10-CM ] codes indicating suspected or confirmed child maltreatment) and/or CPS reports. DESIGN: Three mutually exclusive comparison groups were created: group 1- children with a nonfatal hospitalization and/or emergency department visit with a maltreatment ICD-10-CM code and an investigated CPS report; group 2- children with a maltreatment ICD-10-CM code in a health record without an investigated CPS report; and group 3- children with an investigated CPS report without a health record with a maltreatment ICD-10-CM code. Descriptive statistics and tests for statistically significant differences were conducted. SETTING AND PARTICIPANTS: Wisconsin children with maltreatment ICD-10-CM code in health record and/or CPS-investigated report from 2018 to 2019. MAIN OUTCOME MEASURE: Demographic and maltreatment type differences between groups. RESULTS: Group 1 children were significantly younger than those in other groups ( P <. 001), and group 2 children were significantly more female (69.6%; P < .001). Black children were overrepresented in all groups and most disproportionate among group 1 (39.5%; P < .001). Maltreatment type also differed significantly across groups. CONCLUSIONS: CPS staff and health providers encounter overlapping and nonoverlapping populations of children experiencing different types of maltreatment. Although interventions may be tailored toward the type of maltreatment and other relevant child characteristics, all populations could benefit from referrals and access to supportive social services. Agency contact provides an opportunity to intervene and support at-risk children and families.

The Effects of Opioid Use during Pregnancy on Infant Health and Well-Being.

In this study, we estimate the first causal effects of in utero opioid exposure on infant health at birth and child protective services reports. We employ maternal fixed-effects models using linked administrative data capturing 259,723 infants born to 176,224 mothers enrolled in Medicaid between 2010 and 2019. Our preferred specifications suggest that neonatal abstinence syndrome and NICU admission bear strong associations with prenatal opioid exposure, concentrated on illicit and medication assisted treatment (MAT) exposure in the first and third trimesters. We find that prenatal opioid exposure is associated with increased CPS reports, low birth weight, preterm birth, and small for gestational age, though these measures are less sensitive with respect to the timing of exposure. While we detect relatively smaller effects of non-MAT prescription opioid exposure on NAS, NICU admission, low birthweight, these effects are not trivial, suggesting that medical professionals should consider balancing the potential for adverse side effects of infants with the benefits of pain management for pregnant women.

Reducing poverty among children: Evidence from state policy simulations.

State approaches to reducing child poverty vary considerably. We exploit this state-level variation to estimate what could be achieved in terms of child poverty if all states adopted the most generous or inclusive states' policies. Specifically, we simulate the child poverty reductions that would occur if every state were as generous or inclusive as the most generous or inclusive state in four key policies: Supplemental Nutrition Assistance Program (SNAP), state Earned Income Tax Credits (EITC), Temporary Assistance for Needy Families (TANF), and state Child Tax Credits (CTC). We find that adopting the most generous or inclusive state EITC policy would have the largest impact on child poverty, reducing it by 1.2 percentage points, followed by SNAP, TANF, and lastly state CTC. If all states were as generous or inclusive as the most generous or inclusive state in all four policies, the child poverty rate would decrease by 2.5 percentage points, and five and a half million children would be lifted out of poverty.

Poverty among Foster Children: Estimates Using the Supplemental Poverty Measure.

We use data from the Current Population Survey and the new Supplemental Poverty Measure (SPM) to provide estimates for poverty among foster children over the period 1992 to 2013. These are the first large-scale national estimates for foster children who are not included in official poverty statistics. Holding child and family demographics constant, foster children have a lower risk of poverty than other children. Analyzing income in detail suggests that foster care payments likely play an important role in reducing the risk of poverty in this group. In contrast, we find that children living with grandparents have a higher risk of poverty than other children, even after taking demographics into account. Our estimates suggest that this excess risk is likely linked to their lower likelihood of receiving foster care or other income supports.

Young child poverty in the United States: Analyzing trends in poverty and the role of anti-poverty programs using the Supplemental Poverty Measure.

Between 1968 and 2013, the poverty rate of young children age 0 to 5 years fell by nearly one third, in large part because of the role played by anti-poverty programs. However, young children in the U.S. still face a much higher rate of poverty than do older children in the U.S. They also continue to have a much higher poverty rate than do young children in other developed countries around the world. In this paper, we provide a detailed analysis of trends in poverty and the role of anti-poverty programs in addressing poverty among young children, using an improved measure of poverty, the Supplemental Poverty Measure. We examine changes over time and the current status, both for young children overall and for key subgroups (by child age, and by child race/ethnicity). Our findings can be summarized in three key points. First, poverty among all young children age 0-5 years has fallen since the beginning of our time series; but absent the safety net, today's poverty rate among young children would be identical to or higher than it was in 1968. Second, the safety net plays an increasing role in reducing the poverty of young children, especially among Black non-Hispanic children, whose poverty rate would otherwise be 20.8 percentage points higher in 2013. Third, the composition of support has changed from virtually all cash transfers in 1968, to about one third each of cash, credit and in-kind transfers today.