Life for a newborn whose mother is addicted to heroin is precarious. And for the most part, it’s up to hospitals to save the lives of the tiniest victims of opioid addicts.
While state policymakers have spent the past two years focused on ways to stem the epidemic of heroin and other opioids across the state, healthcare professionals across New Jersey are using every means at their disposal, including medication, to wean these babies off their dependence.
One of the focal points for this effort is PSE&G Children’s Specialized Hospital in New Brunswick, which has had a program devoted to infants struggling with withdrawal. It’s also a place that’s developing techniques that could be replicated elsewhere.
Program director Dr. Sharon Burke said the hospital has been treating babies going through withdrawal, known as neonatal abstinence syndrome (NAS), for many years. However, a rising number of cases prompted Children’s Specialized to launch a program dedicated to these newborns five years ago. Since then, the numbers and the severity of the cases have continued to grow.
Nationally, the number of babies born with NAS has risen from 1.2 per 1,000 births in 2000 to 3.4 in 2009, according to an article in the “Journal of the American Medical Association”. While numbers specific to New Jersey aren’t available, experts said the state saw a similar increase, which has only worsened in the past five years.
The symptoms these babies have are distressing and complex. For example, they can develop in a way that is out of synch with their opioid-addicted mothers, which can cause their pulse to speed up when the mother’s slows down.
In normal development, fetal heart rate tracks the mother’s. Further, even full-term babies with NAS are often undersized.
Once infants are born and their umbilical cords are cut, the flow of chemicals from their mothers stops. A baby’s heart rate can spike to 200 beats per minutes, raising the possibility of the heart stopping; muscles may tense, pulling the arms and hips inward; and the infant may have severe diarrhea or constipation, as well as reflux, which may prevent them from feeding.
Each of these symptoms and many others must be carefully checked, monitored and addressed. The hospital treats one to four babies at a time, with the treatment generally lasting four weeks.
Burke said there aren’t many programs that combine the use of medications with expert therapists — including those who specialize in how newborns eat, breathe, move, and learn — that are available at a hospital devoted to children.
Children’s Specialized has honed this approach, combining careful use of methadone and morphine, along with therapies that essentially teach babies to develop the instincts that other infants have naturally.
“They’re very disorganized and their orientation to sensory input is abnormal — these babies don’t like to be held,” she said. So through gentle handling and rocking, quiet music and dark rooms, the hospital staff works with parents and volunteers to slowly coax the babies to develop the ability to soothe themselves. They also work with the babies to focus on human faces rather than on toys, while using their hands to explore their environment rather than keeping them clenched.
Perhaps most importantly, therapists work with the babies to improve their ability to feed, timing their sucking, swallowing, and breathing in a way that would come naturally if not for withdrawal.
“You want to engage these muscles and you want to help the babies’ pace,” Burke said. “ We do it instinctively. These babies many times do not.”
The hospital also draws on some unusual therapies, including aquatic therapy in a pool that many babies find calming; electro-stimulation of the babies’ throat muscles to help with feeding; and using elastic tape to help babies stretch and relax their muscles. This also helps the baby’s learn how to breathe at a more normal pace.
“They don’t know how to pace themselves — they’re like a little choo-choo train,” said Burke, who naturally moves from clinical language to expressing empathy for her patients.
Burke emphasized the importance of taking extra precautions at a time when the babies with NAS are at an increased risk of sudden infant death syndrome. For example, the hospital checks every baby’s heart rate and blood-oxygen levels, as well as whether they have apnea, to minimize their SIDS risk.
Burke said that the symptoms that each baby experiences can long outlast their immediate withdrawal.
In some neonatal intensive care units, after the weaning process is complete, “the story stops there, and we believe the story needs to go further,” she said.
Her program follows up with the children’s parents or guardians after they are discharged, monitoring for symptoms and making sure that the infants continue to receive needed care. The hospital also works with the state Division of Protection and Permanency to help the babies find supportive homes. While some mothers visited their newborns daily, others are in inpatient addiction treatment programs, so grandmothers and aunts or foster parents sometimes are trained by the hospital to care for the infants.
The babies’ mothers range from longtime illicit drug users who are taking methadone to those who recently began to misuse prescription pain relievers.
When the symptoms appear depends on which drugs the mother took. Babies exposed to morphine go into withdrawal one to three days after being born, while methadone exposure can lead to withdrawal up to a week later. and those exposed to other drugs can take more than a week to have severe symptoms.
Burke said nurses should be on the lookout for mothers who have a history of drug use, so that they can observe their babies for potential symptoms before they go home.
“We used to as a society point a finger at these mothers and say you’re a bad mother,” Burke said, which led to mothers withholding their histories, threatening both their own health and that of their babies. “Today we know that’s not the right approach,” leading doctors to emphasize the need for honesty.
Burke said there isn’t enough data about how babies with NAS develop after their initial treatment is completed. Therefore, two of pediatricians at the hospital who specialize in how babies’ brains and nervous systems develop have begun to track them through age four.
Burke and her Children’s Specialized colleague Dr. Anna Malia Beckwith, who works at the hospital’s Mountainside location, published an article in the journal “Clinical Pediatrics” in September that found that some babies who have been weaned off the drugs still struggle with issues like feeding and responding to voices.
Dr. Barry Weinberger, chief of neonatology at Robert Wood Johnson Medical School, compared the increase in babies with NAS to the surge in babies affected by crack cocaine in the 1980s. He oversees three units treating babies with NAS at the RWJ University Hospital campuses in New Brunswick, Hamilton, and Somerset. He credited Children’s Specialized for doing good work with babies who have needs that extend beyond their first week of life, including those with more severe symptoms.
“The best way to manage these children is as a partnership between the acute care and the long-term care,” Weinberger said.
In addition, the newborns have greater need for social supports, since they by definition come from troubled family backgrounds.