At Yale New Haven Children’s Hospital, the protocol for treating newborns with neonatal abstinence syndrome (NAS) had remained the same for decades.
Like most U.S. hospitals, Yale Children’s doctors used the “Finnegan” tool—a method developed in the 1970s—to assess babies for signs of drug withdrawal. If the newborns met the threshold for NAS, they were transferred to the neonatal intensive care unit (NICU). They were separated from their mothers and treated with medication in a hectic environment punctuated by the sounds of beeping monitors, busy clinicians, and cries from other infants.
But in 2010, with rising numbers of babies affected by their mothers’ opioid use, Matthew Grossman, MD, assistant professor of pediatrics at Yale School of Medicine and the quality and safety officer at Yale Children’s, led the medical center in taking a second look at the approach—with good reason.
“We saw a dramatic reduction in our length of stay [of babies with neonatal abstinence syndrome]. Our length of stay went from twenty-two and a half days to six days."
Matthew Grossman, MD
Yale School of Medicine
The average length of stay in the NICU for NAS babies around the country then was about 23 days, says Grossman. “[NAS hospital stays were] really the longest length of stay outside of prematurity in pediatrics,” he notes. “We found the reason we were doing what we were doing today is because that’s what we were doing yesterday, and there really wasn’t much evidence beyond that. So we started to challenge the standard approach.”
To start, Yale Children’s shifted away from pharmacologic approaches, in which infants were gradually weaned off of opioids, as the first line of treatment for NAS. Their new method, called theapproach, centers on a low-stimulation environment that keeps babies and moms together so infants can breastfeed on demand and benefit from the soothing touch of their mothers.
“We found the parent was really the key to this,” Grossman says. “After we did this, we saw a dramatic reduction in our length of stay, much below the national average. Our length of stay went from twenty-two and a half days to six days.”
Yale Children’s is one of many academic medical centers across the country working to aid the growing numbers of pregnant women and newborns affected by opioid use. According to the National Institute on Drug Abuse, the number of babies born with NASfrom 2000 to 2012, affecting an estimated 21,732 infants. Efforts spearheaded by medical schools and teaching hospitals range from early screening of pregnant women to supporting families with services after a baby is born.
Monday, April 16, 2018
Neonatal Abstinence Syndrome: The Basics
Between 55% and 94% of babies born to mothers addicted to or treated with opioids while pregnant may develop neonatal abstinence syndrome (NAS), according to a 2016 New England Journal of Medicine article. Common signs of NAS include tremors, poor feeding, breathing problems, and fever.
Measurement and management of the syndrome vary among hospitals, the NEJM article notes. Traditionally, treatment has included medication such as methadone or morphine for babies with moderate to severe NAS signs. However, more recent data reported in Pediatrics point to the benefits of nonpharmacologic approaches, including breastfeeding when appropriate and physical touch by caregivers.
A 2017 American College of Obstetricians and Gynecologists committee opinion related to opioid use offers several recommendations, including early universal screening of pregnant women, medication-assisted treatment for those with opioid use disorder, and connecting parents to social services.
Helping babies, supporting moms
In 2015 and 2016, nearly 10% of babies born at the Children’s Hospital at Dartmouth-Hitchcock in New Hampshire were at risk for opioid withdrawal. Like at Yale Children’s, leaders there decided to promote more connection between moms and babies.
Physicians began allowing infants to remain in their mothers’ rooms for the full hospital stay in 2014, explains Alison V. Holmes, MD, MPH, pediatric hospitalist and associate professor of pediatrics at Geisel School of Medicine at Dartmouth. The result was, fewer withdrawal symptoms, and shorter hospital stays.
In addition, the Dartmouth-Hitchcock team reached out earlier—working with opioid-using women while they were pregnant—to help them prepare for their hospital experience.
Beginning in 2013, Dartmouth-Hitchcock obstetricians, pediatricians, and midwives collaborated with local providers to identify pregnant women at risk for delivering opioid-exposed babies. The program, which has helped nearly 500 mothers so far, includes medical students and residents in efforts to educate and support pregnant women at the hospital and in community-based treatment programs.
“Basically, we said, we need to get the message out way before the day the baby is born that these babies require a special type of care and a quiet environment,” Holmes explains. “They require a lot of holding, a lot of snuggling. We need the family to be expecting to stay longer because we need to watch for withdrawal symptoms for at least four days.” In addition, she notes, “we wanted them to know . . . what they could do to help their baby do better.”
Through these efforts, Dartmouth-Hitchcock found that mothers had an improved overall experience at the hospital and bonded better with their babies, says Holmes, who received a 2015 AAMCfor the program.
At both Dartmouth-Hitchcock and Yale Children’s, staff training was a key component in improving experiences and ensuring more involvement from mothers.
Pregnant women who had exposed their babies to opioids often felt judged negatively by hospital staff and therefore uncomfortable and unsupported, Grossman says. Educating staff to treat all mothers with the same respect made a marked difference, he notes.
“We said, ‘We want this to be a good experience for everybody, and our role here is as coaches and cheerleaders,’” he says. “By the end of our project, the culture change at our institution was remarkable, and the feeling of empowerment and confidence in the parents has been amazing.”
Uniting specialists to promote recovery
At Massachusetts General Hospital (MGH), a key focus is postpartum support for mothers involved in opioid use.
In fact, MGH is launching a new clinic designed partly to meet needs these women often face after delivery, explains Sarah Wakeman, MD, medical director for the Substance Use Disorders Initiative at MGH and assistant professor of medicine at Harvard Medical School. Wakeman notes that Massachusetts Department of Public Health data show a steep increase in opioid overdose in the 6-to-12-month postpartum period.
“These grim statistics validated what we anecdotally had seen to be true—during pregnancy women and families get a lot of support but after the initial postpartum period those supports generally dissipate, and for some families this can mean the bottom falls out,” Wakeman says.
“Our message all along is that we are in this together, and our shared mission is to take better care of the patients we are serving.”
Sarah Wakeman, MD
Massachusetts General Hospital
The clinic, which is set to open in April 2018, will bring together various care providers in a single clinic so that many needs can be met in one place. Services will include addiction medicine, obstetrics care, adult and pediatric care, psychiatry, social work, and recovery coaching.
Research shows that when substance users receive such “wraparound” services, their outcomes improve. For example, a 2005by the Substance Abuse and Mental Health Services Administration found that women who received various services at the same time, such as child care, prenatal care, and mental health services, had decreased substance use, HIV-risk reduction, increased self-esteem, and improved perinatal outcomes.
Caring for families dealing with the effects of opioid use requires coordination between providers, especially at a time when mothers are most vulnerable, Wakeman notes.
“The most important ingredient is partnership. You need champions from all the different departments,” she says. “Our message all along is that we are in this together, and our shared mission is to take better care of the patients we are serving.”
Novel strategies target NAS in West Virginia
In West Virginia, where NAS rates are theaccording to recent Centers for Disease Control and Prevention data, academic health care leaders have developed innovative NAS services.
One such initiative is Lily’s Place, an inpatient facility that provides therapeutic and pharmacological care to NAS babies that was created by providers from the Marshall University Joan C. Edwards School of Medicine, Cabell Huntington Hospital in Huntington, and community organizations. The facility is the first approved by the Centers for Medicare & Medicaid Services for a new, more flexible NAS services payment model.
Lily’s Place offers a supportive transition before returning home, explains James B. Becker, MD, an expert in addiction medicine and vice dean for government affairs and health care policy at the Edwards School of Medicine. “The environment of Lily’s Place is very quiet and comforting for these infants,” says Becker. In addition, the facility frees up beds in the NICU for other sick infants, he notes.
And soon, West Virginia mothers struggling with drug addiction will be able to stay at Project Hope, a facility Marshall University and Marshall Health are creating to help mothers maintain safe, sober living while caring for their children.
“Patients [with substance use disorders] are frequently in living situations in which they and their children are subject to violence, trauma, or neglect,” notes Becker. “The goal is to keep families safe and together.”