Babies in Utero Experience Effects of National Opioid Addiction Epidemic

Posted July 21, 2016 by Wendy Loveland

Opiod Pill Bottle Tipped Over
As opiod has grown, so has neonatal abstinence syndrome. 

Opioid abuse is at a crisis point in the U.S., and it’s affecting more and more babies in utero. Babies born to women who use opioids are cutoff from those drugs at birth, which puts the babies at risk for a cluster of neurological, gastrointestinal and respiratory symptoms that are collectively referred to as neonatal abstinence syndrome (NAS). Nationally, NAS has increased fivefold since 2000, and this rate, too, has become steeper in the past few years. In 2009, one infant was born with NAS per hour. By 2012, one baby was born with NAS every 25 minutes

“We started to see a noticeable increase in NAS in 2012,” says Jodi Jackson, MD, Medical Director NICU at Shawnee Mission Medical Center and a neonatologist at Children’s Mercy Kansas City. “Until then, variability around care of the mother and infant was high, without consensus on the appropriate way to approach the issues. We realized that in order to provide the best care to babies and families, we needed to standardize our treatment protocols, and quickly as the incidence was rising.”

Treatment for NAS is complex, and changes depending on a mother’s drug use profile, such as whether the mother was using an illegal drug like heroin, a prescription opioid pain medication or a combination of multiple drugs, including mood stabilizers. There are scoring tools that help medical professionals determine the appropriate treatment option. Opioid use and specifically opioids in combination with other medications or drugs, put babies at high risk for NAS, which may require intensive intervention. 

“Previously our uninformed approach directed nurses to move the baby straight to the NICU for monitoring and scoring, which decreased the ability to control the environment such as lighting, noise, swaddling and comfort care, and separated the family from the baby,” says Jackson. “We changed that policy to one of keeping the baby with the mother and monitoring the baby there. Rooming-in and skin-to-skin contact with the mother and baby can effectively treat some symptoms of NAS, as such our measurements for the last 2 years have shown a 25 percent decrease in the number of infants requiring medical treatment.” 

If a baby does need medication to prevent severe withdrawals, hospitals have different options. At Children’s Mercy Hospital, morphine is the sole drug used. 

“The reasoning behind using only morphine initially is that all narcotics (synthetic and natural) used for the treatment of withdrawal eventually work by stimulating the opioid receptors. If we use morphine to start, the baby doesn’t have to metabolize the drug, and there is less risk of side effects related to metabolites. Morphine is also predictably short acting and allows for the effects of weaning to be seen quickly, which often results in a shorter duration of treatment” explains Jackson. “Starting with only one drug also allows for improved standardization of care.”

NICHQ, ASTHO and providers from Children’s Mercy are hosting a webinar on NAS on Tuesday, August 16 at 2 pm EST. Register today to learn more about this growing health issue and what strategies are being used to address it.

Empowering Moms
In the midst of managing more babies with NAS, Shawnee Mission Medical Center is educating mothers as fast as they can. Betsy Knappen MSN, APRN, a neonatal nurse practitioner at Shawnee Mission Medical Center and Children’s Mercy Kansas City, is in charge of streamlining the medication and nursing protocols. She and her team lead the education effort by meeting with all families identified one on one to discuss and share educational pamphlets created at Shawnee Mission Medical Center. A multidisciplinary team of neonatal and obstetrical caregivers worked together to create these educational pieces that explain NAS and what to expect, including descriptions of comfort care measures and alternatives to managing pain besides opioids.

“Through the Vermont Oxford Universal Training Modules, and our own local efforts, we have educated all birthing center doctors and nurses and have been designated ‘A Center of Excellence in NAS Care.’ What we would like to do now is to work with community organizations to help educate and treat women before they become pregnant, or early in the pregnancy as well as continue treatment after the baby is delivered” says Knappen. “If you ask mothers whether they are using narcotics, many will answer, ‘No!’ Yet on their medication list, they will list Vicodin, for example. They may not know that Vicodin is a narcotic.” 

“Although this neonatology-led initiative initially focused on treating babies, we are finding it our duty to help mothers who have drug use or abuse issues find treatment. The time around pregnancy and delivery can be an important pivotal period for mothers to embark upon treatment, as they are inspired by the new life growing inside of them,” says Jackson. “It is important for any drug treatment program to be carefully supervised by health care professionals. If not adequately supervised, a pregnant woman might experience serious withdrawal symptoms, the fetus will experience those same symptoms in utero, which can be damaging or even deadly – and we cannot treat the baby for withdrawal in utero.”

Growing Solutions for a Growing Problem
To address this growing public health issue, multiple state and national agencies are now focused on developing best practices for NAS treatment. Some state NAS initiatives, such as the Vermont-Oxford Collaborative, help members with education and share state success stories. Meanwhile, the Association of State and Territorial Health Officials (ASTHO) is supporting organizations at every level to address NAS across the country. 

“We look at state data, recommendations for best practices from federal health agencies such as the Centers for Disease Control and Prevention, and develop recommendations for states,” says Leslie Erdelack, an injury representative at ASTHO. “We respond to requests for technical support and help with prioritizing data gathering approaches. We also make state approaches and success stories available to members.”

ASTHO uses its Spectrum of Prevention, which are primary, secondary and tertiary prevention strategies to address NAS, and has developed a framework found in the report: How State Health Departments Can Use the Spectrum of Prevention to Address Neonatal Abstinence Syndrome. It is an outline with questions designed for states to take an inventory of where they stand in terms of data, prevention strategies and more. 

“NAS is a complex issue and needs a system approach,” says Ellen Schleicher Pliska, MHS, CPH, family and child health director at ASTHO, and a participant in the NICHQ and Maternal and Child Health Bureau led Collaborative Improvement and Innovation Network to Reduce Infant Mortality (IM CoIIN). “It requires collaboration among multiple entities which do not usually work together, such as maternal and child health, insurance, surveillance, primary to tertiary care, substance abuse treatment providers, legislators, law enforcement and social services.”

While NAS is a serious but treatable condition, it will take a large-scale effort to increase awareness for it and educate moms about the risks of using certain medications and drugs while pregnant. Through learning collaboratives and other initiatives, healthcare providers and public health organizations are on the path to helping women improve their health and ultimately the health of their babies.

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