Improve Care for Babies Born Drug Dependent

Introductory Paragraph

Babies who are born with Neonatal Abstinence Syndrome (NAS) experience discomfort and trauma. They may scream, have tremors, and struggle with eating and being comforted. Hospital staff are finding new opportunities to help these babies and their mothers. Approaches based on recent evidence-based research include moving from NICU and pharmacology treatment to a mother-centered approach. This keeps the mother-infant dyad together in a calm setting while encouraging frequent feedings, comforting, and swaddling to treat the baby's opioid dependence.

Key Information

Since the 1970s, pharmacology has been the standard for treating babies born with NAS, and physicians have utilized Methadone or Morphine in treatment. Traditionally infants born drug dependent have been managed in the NICU due to concerns of complications. The Finnegan Score/Finnegan Tool has dictated the care level for babies born drug dependent.

Complications from NAS can include:

• Low birthweight
• Jaundice
• Seizures
• Sudden infant death syndrome (also called SIDS).
• Developmental delays
• Motor problems
• Behavior and learning problems
• Speech and language problems
• Sleep problems
• Ear infections
• Vision problems

Treatment of infants showing signs of withdrawal includes a supportive care approach to treatment, such as creating a dark and quiet environment, swaddling the infant to improve self-stimulation, and providing frequent feedings to reduce infant stress. Other strategies include skin-to-skin contact for comfort and promotion of the infant’s attachment to the mother/caregiver, as well as other comforting techniques such as rocking or swaying the infant. Frequent feedings address hydration level. Breastfeeding has been proven to be an effective approach if the mother is receiving medication-assisted treatment and has no other complications which inhibit breastfeeding. Educating families on methods of care is important to provide ongoing supportive care of the infant.

Eat, Sleep, Console (ESC) Model

Recent research has introduced the ESC approach to treatment of babies born drug dependent. This is a mother-centered approach, based upon the following:

• Eat: Is the baby feeding normally?
• Sleep: Is the baby able to sleep?
• Console: Can the baby be consoled within ten minutes of crying?

The ESC approach may be used alone or in conjunction with the Finnegan's model for scoring. The simple components of the approach have shown a decrease in overall length of hospitalization as well as a decrease in need for a pharmacological approach.

Relevant Research

This article documents the decreased impact of NAS associated with parental time spent at the infant's bedside.

This article is a literature review titled "Eat, Sleep, Console Approach: A Family-Centered Model for the Treatment of Neonatal Abstinence Syndrome." It is an evidenced-based practice brief that summarizes and critically reviews emerging research on the ESC method.

This research study compared treatment decisions of 50 consecutive opioid-exposed infants managed on the inpatient unit at the Yale New Haven Children's Hospital. Infants managed by using the ESC approach were treated with Morphine significantly less frequently than they would have been by using the Finnegan Neonatal Abstinence Scoring System assessment approach. The article is titled, "A Novel Approach to Assessing Infants With Neonatal Abstinence Syndrome."

This literature review on ESC is part of a doctorate in nursing practice. It addresses:

• the need to improve NAS assessment practices
• the benefits of family-centered care
• the need to develop well-structured NAS treatment protocols

Impactful Federal, State, and Local Policies

The Comprehensive Addiction and Recovery Act (CARA) of 2016 amended the Child Abuse and Prevention Treatment Act (CAPTA). This policy brief summarizes how states are required to serve infants and their families affected by prenatal substance exposure. It uses highlights form seven states to unpack the implications for notification and reporting requirements and for plans of safe care.

West Virginia Advocacy. Lily's Place is a neonatal withdrawal center that offers workshops and trainings on legislation to support NAS centers and on planning and funding a NAS center. Its role in advocacy is grounded in direct experience. Lily's Place was the first nonprofit infant recovery center to provide services for parents and families struggling with substance use. The center is specifically designed for babies with NAS with small, quiet, dimly-lit nursery rooms and 24-hour nursing staff. Parents are trained to help their babies via therapeutic handling techniques and they learn CPR and basic child care as well as the specifics of NAS.

Available Tools & Resources

SAFE Project:

• "Addiction and Mental Health Resources for Women" is a guide that includes a number of support resources during and after pregnancy.
• See the wiki titled "Increase Awareness of Risks of SUD on the Baby" for more detailed information on increasing the awareness surrounding the possible risks of drug use during pregnancy.

Canadian Provincial Health Resources, British Columbia provides a practice resource for healthcare providers titled, "Care of the Newborn Exposed to Substances During Pregnancy."

Yale School of Medicine. This webinar is provided by the originator of ESC -- Matthew Grossman, MD, Associate Professor of Pediatrics, Yale-New Haven Children’s Hospital.

The Saskatchewan Health Authority created a handout on ESC for new parents.

The California Healthcare Foundation has a blog that details the benefits of ESC in a highly accessible manner. It is titled "Opioid-Dependent Newborns Get New Treatment: Mom Instead of Morphine."

ESC Toolkit. This downloadable guidebook resulted from a collaboration between doctors at Boston University School of Medicine, Children’s Hospital at Dartmouth-Hitchcock, and Yale University School of Medicine.

Women & Infants Clinical Institute has published an ESC guidebook that includes recommendations, approaches, and resources. The guidebook was developed through collaboration between Bakersfield Memorial Hospital in California, CHI Franciscan in Tacoma, Washington, and the Yale-New Haven Children’s Hospital.

Promising Practices

Kentucky. In Louisville, healthcare workers are using a combination of pacifiers and music therapy to ease the pain of babies born to mothers who used opioids during their pregnancy. They use a special pressurized pacifier that plays music. A music therapist uses music and live-singing in the NICU, patting and rocking to match the baby's behavior state, ultimately training the child to soothe itself. This calming improved feeding and sleeping and decreased their crying -- eliminating three of the major symptoms which lead babies to need medication or hospital stay.

Maryland. The Maryland Patient Safety Center is working with 30 birthing centers to develop standardized care for babies suffering from NAS in order to reduce the length of stay for these babies. Standards include:

• A calming environment with little stimulation - quiet rooms and low lights
• Cuddle rooms where volunteers rock and soothe babies
• Massage and music therapy
• Some medicine (Morphine or Methadone)
• Treatment of mother's addiction and mental health in conjunction with babies' treatment

Pennsylvania. At Magee-Womens Hospital of UPMC, volunteers are helping babies born addicted to opioids by cuddling, nurturing, and comforting the babies as they go through withdrawal. Cuddlers provide them with additional comfort, as opposed to having to start an IV or give a baby Morphine. There are a growing number of programs that have volunteers come to the hospitals to cuddle the babies. This helps comfort the babies and reduces the stress on the nurses--two important benefits.

---