About 1 in 20 women, or 5% of all moms-to-be, abuse illicit drugs during pregnancy. This can lead to major health problems for mother and child, including neonatal abstinence syndrome, (NAS) which is especially prevalent in New Jersey. Rates for NAS are rising to dangerous levels here as a result of the reported spike in drug use during the COVID-19 pandemic.
NAS occurs when newborn babies experience withdrawal after being exposed to drugs such as opioids in the womb, according to the Centers for Disease Control and Prevention. NAS can be extremely painful and life-threatening. Babies with NAS suffer from severe drug withdrawal symptoms that, if not identified and treated in a timely manner, can lead to seizures and even death.
Every 19 minutes, a baby is diagnosed with NAS in the United States. That’s nearly 80 newborns a day, according to 2016 data from the Healthcare Cost and Utilization Project (HCUP.) In New Jersey, there are 6.7 cases of NAS per 1,000 hospital births, according to 2017 data, the most recent available. I believe those statistics are an extreme underestimate, given what we have seen during these troubling times.
At University Hospital in Newark, I have been taking care of babies and children with NAS for over 30 years as a neonatologist. Unfortunately, I have seen with my own eyes how the opioid epidemic and now, the COVID-19 pandemic, have intensified this crisis.
As neonatologists, one of the greatest challenges we face is that a majority of mothers who misuse illicit substances are not identified during their pregnancy. Currently, the only way to identify these mothers is through self-reporting which, according to multiple studies, is 30% to 75% underreported.
Given the numerous risks of maternal complications associated with substance misuse during pregnancy, it is mind-boggling that there is no mandated universal toxicological screening for mothers during pregnancy.
In fact, a majority of hospitals in the United States do not even have policies and procedures for performing risk-based urine toxicology screenings during pregnancy. This prevents pregnant mothers with substance-abuse disorders from getting appropriate care and referrals. It also leads to increased morbidity and mortality for both mother and baby.
Babies who are born to mothers who were misusing substances during pregnancy but who did not report doing so, go home from the well-baby nursery on days one or two of life. However, NAS signs and symptoms don’t even present in a newborn until days four to seven, depending upon the drug in the child’s system.
After going home seemingly “healthy,” many of these babies end up in the ER only a few days later with severe symptoms such as seizures. There they will be seen by doctors who are not well-trained in NAS identification and management and who may expose these newborns to invasive and unnecessary tests such as a spinal tap.
Losing out in the long term
Babies who have been exposed to drugs but do not receive proper follow-up care for NAS also lose out on the necessary long-term specialized developmental follow-ups they need during their childhood and adolescence.
As they get older, if untreated, these children go on to have higher incidences of cognitive and behavioral problems that can lead to an increase in misdiagnosed ADHD and PTSD referrals. Frustration in school can lead to behavior issues, suspensions, criminal activity and drug abuse.
So how do we address this growing crisis? First, we need to consider toxicology screenings for pregnant mothers. We also need to enact standardized protocol and policies, and practice procedure-based care for babies suffering from NAS at every hospital in the country — something a majority of hospitals in the United States are currently lacking.
In order to address the urgent needs facing mothers and babies coping with NAS in our community, I developed NASTOP (Neonatal Abstinence Syndrome Treatment Observation Protocol).
This protocol helps reduce the length of treatment and hospital stay and cuts associated costs of care for NAS by more than 50%.
The NASTOP protocol at University Hospital has been used since 2018 to identify drug-using mothers through a criteria-based urine toxicology screening. These mothers get treated by obstetricians at University Hospital who are certified by the American Society of Addiction Medicine (ASAM.)
Meeting the needs of NAS babies
At birth, babies born to mothers who screened positively for drug use are tested and observed for signs and symptoms of NAS and, if symptomatic, get treated according to the NASTOP treatment protocol. NAS babies’ needs for breast feeding, high caloric nutrition, bonding, rooming in, nonpharmacological and environmental therapy are provided in the form of a standardized policy and procedure-based care.
Supportive-care and referrals for treatment and rehabilitation programs are provided to parents in a compassionate, nonjudgmental manner, with the help of social workers and outreach workers. Since these babies are identified at birth, they also receive follow-ups with the High-Risk Clinic for any nutritional, developmental and behavioral problems until age six.
Establishing NASTOP programs at hospitals nationwide can also increase the number of trained providers at the community level and ensure mandatory universal toxicological screening for mothers and babies, which will save lives.
We also need to designate NAS as a reportable illness, grounding it in public-health principals and eradicating stigma. Establishing post-discharge follow-up programs of NAS-affected infants will also help reduce many of the dangerous and potentially lifelong health risks to both mother and baby.
Especially in the wake of COVID-19, we need to ensure every mom struggling with substance abuse feels safe enough to seek support and every baby has access to the care they need to overcome NAS and live a full life. A pandemic, however great the magnitude, cannot be an excuse to let this critical component of maternal healthcare fall to the wayside. It’s time to enact NAS protocols nationwide now.