Providing Care forDrug-exposed

Newborns: Time forthe Next Step

Dr Allen Cherer

During the years 1999-2013, the amount ofprescription opioids dispensed in the UnitedStates nearly quadrupled, and since 2000, it isestimated that opioid use during pregnancy hastripled. Notably, the tragic consequences of theextreme availability of such drugs include abuse,physical dependence, and increasingly, deaththrough inadvertent overdose.

In addition, for the individual pregnant woman, aminimum of two lives is affected: her own and that of herunborn child. The prevalence of prenatally exposednewborns to one or more illicit drugs approximates 6%.Neonatal Abstinence Syndrome (NAS) refers to thewithdrawal symptoms from physical dependenceexperienced by the newborn exposed during pregnancygenerally to illicit drugs, prescribed drugs, or to thoseopioids employed in medication-assisted treatment ofmaternal opioid addiction.

Withdrawal symptoms can vary markedly in terms of time ofonset and severity but typically manifest as tremulousness,agitation, sleeplessness, and poor feeding. NAS increasedthreefold from 2000-2009 and frequently requires prolongednewborn hospitalization. It has been reported that aggregatehospital charges for NAS increased from 732 million dollars to1.5 billion dollars with approximately 80% attributed to stateMedicaid programs in 2012. Clearly, NAS is a costly publichealth problem resulting in significant human suffering andexpense.

Traditionally, infants who are known to be at risk for NAS havebeen monitored in the postpartum unit after birth for at least 96hours and withdrawal symptoms scored based on the FinneganScale developed in the mid 1970’s. Typically, if the scores exceedcertain values, the newborn is admitted to a Special Care Unitwhere pharmacologic treatment is frequently started. Aswithdrawal symptoms subside, dosing is gradually tapered andultimately stopped. The newborn is observed off medication andmonitored for recurrence of disabling withdrawal symptoms.The entire process can generally result in a prolonged SpecialCare Unit hospital stay of 2-10 weeks.

With the seemingly overnight explosion in the number ofnewborns demonstrating withdrawal symptoms in the early2000’s, medical caregivers and hospitals were caught off-guard. On short notice, staff addiction education, medicationand weaning protocols, general care policies, and hospitalspace allocation were required. After a number of years ofconcerted, collaborative work, much has been learned andachieved in improving the care of the substance-exposedinfant.

Nevertheless, pharmacologic treatment continues to requireprolonged hospital stays, often in costly Special Care Units. Inaddition, it effectively excludes full participation by theeventual sole primary caregivers, ideally the parents. It is withthese disturbing issues in mind that it is refreshing to note thework and studies over the past several years to furtheroptimize the care provided to infants with NAS and theirfamilies.

One of the earlier studies to suggest the therapeutic benefits of adifferent approach to caring for the drug-exposed infant wasthat of Abrahams et al. published in the Canadian FamilyPhysician in 2007. During the same period of frenzy involvinginpatient hospital transfers, guaranteeing interobserver scoringreliability, pharmacologic treatment protocols, and nursing caredirectives, the Canadian group with extensive previousexperience in addiction medicine reported in a retrospectivecohort study the benefits of a rooming-in policy whereby infantsremained with their mothers as primary caretakers.

They noted that infants who roomed-in were less likely torequire pharmacologic therapy for withdrawal and morelikely to be discharged to mother’s care compared to infant’swho received standard nursery care. Subsequently, otherretrospective cohort studies both in Europe and the UnitedStates demonstrated equally beneficial effects of rooming-inregarding decreased requirement for pharmacologictherapy and decreased duration of hospital stay.

Most recently, the results of a quality collaborative project fromthe Children’s Hospital at Dartmouth Hitchcock were describedin the May, 2016 Pediatrics and demonstrated the beneficialeffects of combined standardized protocols and family-centeredcare in the management of the drug-exposed infant. Over time,the project safely reduced the number of infants requiringpharmacologic therapy, average length of stay, and overallhospital costs.

Among others, key drivers to success were prenataleducation of family caregivers including expressedexpectation that they would provide meaningful rooming-incare, baby-centered NAS scoring including on demandfeeding schedules, pharmacologic therapy when necessarywith dosing adjustment based on overall infant conditionrather than solely Finnegan score and determined by aconsistent team, and an infant “snuggler” volunteerprogram to assist families when times required theirabsence.

Overall, the project demonstrated that despite manypractical obstacles to providing high quality care fordrug-exposed newborns and their families in thehospital setting, where there’s a will, there’s a way.